Standing Orders/Scheme of Delegation/Standing Financial ... · SECTION D – STANDING FINANCIAL...

Oxford University Hospitals TB2011.61

TB2011.61_SOs and SFIs November 2011 1 Page 1 of 4

Trust Board Meeting: Thursday 3 November 2011

TB2011.61

Title Standing Orders/Scheme of Delegation/Standing Financial Instructions

Purpose of paper For Board members to approve the Standing Orders/Scheme of Delegation/Financial Instructions.

Board Lead(s) Mr Mark Mansfield, Director of Finance and Procurement



Key purpose – make bold the relevant word(s)

Strategy Assurance Policy Performance

Strategic Objectives SO5 To meet the challenges of the current economic climate and the changes in the NHS and become a resilient, flexible and successful Foundation Trust

SO6 To achieve the integration of the ORH and the NOC during 2011/2012, realising the benefits as set out in the business case

Links to Board Assurance Framework/Trust Key Risks/CQC Registration

It is a key part of the governance framework for the Trust.

Resource and financial impact N/A

Consideration of legal/ equality /diversity/engagement/risk issues

The adoption of Standing Orders/Standing Financial instructions is a key deliverable for the Trust.



Standing Orders/Standing Financial Instructions for Oxford University Hospitals NHS Trust

Introduction

1. As part of the preparatory work in preparation for the creation of the Oxford University Hospitals NHS Trust, work has been undertaken on the formulation of a set of Standing Orders / Scheme of Delegation / Standing Financial Instructions for the Trust Board to adopt at its first meeting in November 2011.

Overview

Process

2. This document is based on the latest national guidance published by the Department of Health (in March 2006) along with the current ORH and NOC documents, and recent exemplars from other NHS organisations. It is designed to be kept on the intranet for ease of reference and future amendment. Earlier drafts have already been considered by a wide range of staff within the two former trusts, and where appropriate, their suggestions incorporated into the attached document.

Changes from Previous ORH / NOC Documents

3. As drafted, the document incorporates the proposed committee structure and terms of reference and the proposed financial limits are the same as the current ORH documents with the exception of :-

3.1. The value of contracts which the Trust Board reserve the right to approve raised from £100,000 to £1,000,000. (page 39)

3.2. Introduction of limits on the authority to sign NHS Service Agreements (not included in previous ORH documents – page 98)

4. Other changes proposed include:-

4.1. Inclusion at section 3.15 (page 20) of a requirement that all Trust Board members should be required to attend at least 50% of meetings held in any 12 month period.

4.2. National guidance to be adopted in respect of the approval of the Annual Report and Accounts as a decision reserved to the Trust Board (page 40)

4.3. Inclusion at section 11.3 (page 73) of a requirement that all managers in receipt of an audit report have a duty to take appropriate remedial action within the timescales specified in the report.

4.4. The addition at section 16.5 (page 83) of a provision on Money Laundering.

4.5. The updating of section 17 on Tendering and Contracting including references to E-tendering, the use of electronic auctions and ICT procurement



4.6. The addition of section 31 (page 120) on Research & Development.

5. In addition there are a number of other minor changes to reflect updated titles of organisations, changes in legislation (e.g. the introduction of the Bribery Act 2010) and changes of titles within the Trust.

Future arrangements

6. The attached documents have been prepared for the Trust to meet current requirements; however, they will require further minor adjustments, in due course, to meet the requirements of a Foundation Trust. These adjustments will be made at an appropriate time in the future.

Conclusion

7. The adoption of these documents will ensure that the Trust has an appropriate framework in place. Arrangements will be made to ensure that they are brought to the attention of all staff and that they are readily accessible.

Recommendation

8. The Trust Board is recommended to adopt the attached Standing Orders / Scheme of Delegation / Standing Financial Instructions.

Mr Mark Mansfield, Director of Finance

Mr Richard Gardner, Assistant Director of Finance, NOC

October 2011

Policy ID Number: 000 Version: 1

Issue Date: November 2011 Review Date: November 2012

Author/title: Richard Gardner NOC Overall Responsibility: Chief Executive / Director of Finance

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Oxford University Hospitals NHS Trust

STANDING ORDERS, RESERVATION AND DELEGATION of POWERS and STANDING FINANCIAL INSTRUCTIONS

November 2011

Draft -21st October 2011

Approved by Trust Board [3rd November 2011] Once printed off, this is an uncontrolled document. Please check the intranet for the most up to date copy.

OUH NHS Trust ~ Standing Orders November 2011 2

CONTENTS Page

SECTION A INTERPRETATION AND DEFINITIONS FOR STANDING ORDERS AND STANDING FINANCIAL INSTRUCTIONS

8

SECTION B – STANDING ORDERS

1. 1.1 1.2 1.3 1.4

INTRODUCTION Statutory Framework NHS Framework Delegation of Powers Integrated Governance

10 10 11 11

2.

THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF MEMBERS

2.1 2.2 2.3

Composition of the Trust Board Appointment of the Chairman and Members Terms of Office of the Chairman and Members

12 12 12

2.4 2.5 2.6

Appointment and Powers of Vice-Chairman Joint Members HealthWatch

12 13 13

2.7 2.8 2.9 2.10

Role of Members Corporate Role of the Board Schedule of Matters Reserved to the Board and Scheme of Delegation Lead Roles for Board Members

13 14 15 15

3. 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

MEETINGS OF THE TRUST Calling Meetings Notice of Meetings and the business to be transacted Agenda and Supporting Papers Petitions Notice of Motion Emergency Motions Motions: Procedure at and during a meeting (i) who may propose (ii) contents of motions (iii) amendments to motions (iv) rights of reply to motions (v) withdrawing a motion (vi) motions once under debate Motion to Rescind a Resolution

16 16 16 16 16 17 17

18 3.9 3.10 3.11 3.12 3.13

Chairman of meeting Chairman‟s ruling Quorum Voting Suspension of Standing Orders

18 19 19 19 20

3.14 3.15 3.16 3.17 3.18

Variation and amendment of Standing Orders Record of Attendance Minutes Admission of public and the press Observers at Trust meetings

20 20 20 21 22


CONTENTS

Page

4. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8

APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES Appointment of Committees Joint Committees Applicability of Standing Orders and Standing Financial Instructions to Committees Terms of Reference Delegation of powers by Committees to Sub-Committees Approval of Appointments to Committees Appointments for Statutory functions Committees to be established by the Trust Board

23 23 23 23 23 23 24 24

4.8.1 4.8.2 4.8.3 4.8.4 4.8.5 4.8.5

Audit and Finance Committee Remuneration & Appointments Committee (R&A) Quality Committee Board in Committee Trust Management Executive Other Committees

24 24 24 25 25 26

5.

ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION

5.1 5.2 5.3

Delegation of functions to Committees, Officers or other bodies Emergency powers and urgent decisions Delegation of Committees

27 27 27

5.4 5.5 5.6

Delegation to Officers Schedule of matters reserved to the Trust and Scheme of Delegation of Powers Duty to report non-compliance with Standing Orders and Standing Financial Instructions

28 28 28

6.

OVERLAP WITH OTHER TRUST POLICY STATEMENTS/PROCEDURES, REGULATIONS AND THE STANDING FINANCIAL INSTRUCTIONS

6.1 6.2 6.3 6.4

Policy statements: general principles Specific Policy statements Standing Financial Instructions Specific guidance

29 29 29 29

7.

DUTIES AND OBLIGATIONS OF BOARD MEMBERS, MEMBERS, DIRECTORS AND SENIOR MANAGERS UNDER THE STANDING ORDERS AND STANDING FINANCIAL INSTRUCTIONS

7.1 7.1.1 7.1.2 7.1.3 7.1.4 7.1.5 7.1.6 7.2 7.3 7.3.1 7.3.2 7.3.3

Declaration of Interests Requirements for Declaring Interests and applicability to Board Interests which are relevant and material Advice on Interests Record of Interests in Trust Board minutes Publication of declared interests in Annual Report Conflicts of interest which arise during the course of a meeting Register of Interests Exclusion of Chairman and Members in Proceedings on Account of Pecuniary Interest Definition of terms used in interpreting „Pecuniary‟ interest Exclusion in proceedings of the Trust Board Waiver of Standing Orders made by the Secretary of State for Health

30 30 30 31 31 31 31 31 31

31 32 33

7.4 7.4.1 7.4.2 7.4.3

Standards of Business Conduct Policy - Trust Policy and National Guidance - Interest of Officers in Contracts - Canvassing of, and Recommendations by, Members in relation to appointments

34 34 34 35


CONTENTS

Page

7.4.4 - Relatives of Members or Officers 35 8.

CUSTODY OF SEAL, SEALING OF DOCUMENTS AND SIGNATURE OF DOCUMENTS

8.1 8.2 8.3 8.4

Custody of Seal Sealing of Documents Register of Sealing Signature of documents

36 36 36 36

9.

MISCELLANEOUS

9.1

Joint Finance Arrangements

37

9.2 Working with others 37 SECTION C - RESERVATION and DELEGATION of POWERS Decisions Reserved to the Board 38 Decisions /duties delegated by the Board to Committees 42 Scheme of Delegation derived from the Accountable Officer Memorandum 48 Scheme of Delegation derived from the Codes of Conduct and Accountability 50 Scheme of Delegation from Standing Orders 53 Scheme of Delegation from Standing Financial Instructions 55

SECTION D – STANDING FINANCIAL INSTRUCTIONS

10. 10.1 10.2 10.2.1 10.2.4 10.2.6

INTRODUCTION General Responsibilities and delegation The Trust Board The Chief Executive and Director of Finance and Procurement The Director of Finance and Procurement

68 68 68 69 69

10.2.7 10.2.8

Board Members and Employees Contractors and their employees

70 70

11.

AUDIT

11.1

Audit and Finance Committee

71

11.2 Director of Finance and Procurement 71 11.3 11.4 11.5 11.6

Role of Internal Audit External Audit Fraud and Corruption Security Management

72 73 73 73

12.

RESOURCE LIMIT CONTROL

75

13.

ALLOCATIONS, PLANNING, BUDGETS, AND MONITORING BUDGETARY CONTROL

13.1 Preparation and approval of Plans and Budgets 76 13.3 Budgetary Delegation 76


CONTENTS

Page

13.4 Budget Control and Reporting 77 13.5 Capital Expenditure 78 13.6 Monitoring Returns 78 14.

ANNUAL ACCOUNTS AND REPORTS

79

15.

BANK AND GOVERNMENT BANKING SERVICE (GBS) ELECTRONIC ACCOUNTS

15.1 General 80 15.2 Bank and GBS Accounts 80 15.3 Banking Procedures 80 15.4 Tendering and Review 81 16.

INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

16.1 Income Systems 82 16.2 Fees and Charges 82 16.3 Debt Recovery 82 16.4 Security of Cash, Cheques and other Negotiable Instruments 82 16.5 Money Laundering 83 17.

TENDERING AND CONTRACTING PROCEDURE

17.1 17.2 17.3 17.4 17.5 17.5.1 17.5.2 17.5.3 17.5.4 17.5.5 17.5.6 17.5.7

Duty to comply with Standing Orders and Standing Financial Instructions EU Directives Governing Public Procurement Reverse eAuctions Capital Investment Manual and other Department of Health guidance Formal Competitive Tendering General Applicability Health Care Services Exceptions and instances where formal tendering need not be applied Fair and Adequate Competition List of Approved Firms Building and Engineering Construction Works Items which subsequently breach thresholds after original approval

84 84 84 84 84 84 84 84 86 86 86 87

17.6 17.6.1 17.6.2 17.6.3 17.6.4 17.6.5 17.6.6 17.6.7 17.6.8 17.6.9 17.6.10

Contracting/Tendering Procedure Invitation to tender Receipt and safe custody of tenders Opening tenders and Register of tenders E-Tenders Admissibility Late tenders Acceptance of formal tenders (See overlap with SFI No. 17.7) Tender reports to the Trust Board List of approved firms (see SFI No. 17.5.5) Exceptions to using approved contractors

87 87 87 87 88 89 89 89 90 90 91

17.7 17.7.1 17.7.2 17.7.3 17.7.4

Quotations: Competitive and Non-Competitive General Position on quotations Competitive Quotations Non Competitive Quotations Quotations to be within Financial Limits

91 91 91 91 92

17.8 Authorisation of Tenders and Competitive quotations 92 17.9

Instances where formal competitive tendering or competitive quotation is not required

92


CONTENTS

Page

17.10 17.11 17.12 17.13

Private finance for capital procurement (see overlap with SFI No. 24) Compliance requirements for all contracts Personnel and Agency or temporary staff contracts Health Care Service Agreements (see overlap with SFI No. 18)

92 93 93 93

17.14 17.15 17.16

Disposals (see overlap with SFI No. 26) In-house Services Applicability of Tendering and Contracting SFIs to funds held in trust (see overlap with SFI No. 29)

94 94 94

17.17 Cancellation of Contracts 95 17.18 Determination of Contracts for Failure to Deliver Goods or Material 95 17.19 Use of Electronic Auctions 95 17.20 ICT procurement 97 18.

NHS SERVICE AGREEMENTS FOR PROVISION OF SERVICES

18.1 Service Level Agreements 98 18.2 Involving Partners and jointly managing risk 98 18.3 Reports to Board on SLAs 98 19.

COMMISSIONING

99

20.

TERMS OF SERVICE, ALLOWANCES AND PAYMENT OF MEMBERS OF THE TRUST BOARD AND EMPLOYEES

20.1 Remuneration and Terms of Service (see overlap with SO No4) 100 20.2 Funded Establishment 100 20.3 Staff Appointments 101 20.4 Processing Payroll 101 20.5 Contracts of Employment 102 21.

NON-PAY EXPENDITURE (see overlap with SFI No. 17)

21.1 Delegation of Authority 103 21.2 Choice, Requisitioning, Ordering, Receipt and Payment for goods and services

(see overlap with Standing Financial Instruction No 17) 103

21.3 Joint Finance Arrangements with Local Authorities and Voluntary Bodies (see overlap with Standing Order No 9.1)

106

22.

EXTERNAL BORROWING

107

22.2 Investments 107 23.

FINANCIAL FRAMEWORK

108

24.

CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

24.1 Capital Investment 109 24.2 Private Finance (see overlap with SFI No 17.10) 110 24.3 Asset Registers 110 24.4 Security of Assets 111 25.

STORES AND RECEIPT OF GOODS

25.1 General Position 112


CONTENTS

Page

25.2 Control of Stores, Stocktaking, condemnations and disposal 112 25.3 Goods supplied by NHS Supply Chain 112 26.

DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENT (See overlap with SFI 17)

26.1 Disposals and Condemnations 113 26.2 Losses and Special Payments 113 27

INFORMATION TECHNOLOGY

27.1 Responsibilities and duties of the Director of Finance and Procurement 115 27.2 Responsibilities and duties of other Directors and Officers in relation to computer

systems of a general application 115

27.3 Contracts for computer services with other health bodies or outside agencies 116 27.4 Risk Assessment 116 27.5 Requirements for computer systems which have an impact on corporate financial

systems 116

28.

PATIENTS‟ PROPERTY

117

29.

FUNDS HELD ON TRUST

118

30.

ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT

119

31.

RESEARCH AND DEVELOPMENT

120

32.

RETENTION OF RECORDS

121

33.

RISK MANAGEMENT AND INSURANCE

33.1 Programme of Risk Management 122 33.2 Insurance: Risk Pooling Schemes administered by NHSLA 122 33.3 Insurance arrangements with commercial insurers 122 33.4 Arrangements to be followed by the Board in agreeing insurance cover 123

Policy ID Number: 000 Version: 1

Issue Date: November 2011 Review Date: November 2012

Author/title: Richard Gardner NOC Overall Responsibility: Chief Executive / Director of Finance

8 of 123

SECTION A 1. INTERPRETATION AND DEFINITIONS FOR STANDING ORDERS

AND STANDING FINANCIAL INSTRUCTIONS

1.1 Save as otherwise permitted by law, at any meeting the Chairman of the Trust shall

be the final authority on the interpretation of Standing Orders (on which they should be advised by the Chief Executive or Secretary to the Board).

1.2 Any expression to which a meaning is given in the National Health Service Act

1977, National Health Service and Community Care Act 1990 and other Acts relating to the National Health Service or in the Financial Regulations made under the Acts shall have the same meaning in these Standing Orders and Standing Financial Instructions and in addition:

1.2.1 "Accountable Officer" means the NHS Officer responsible and accountable for

funds entrusted to the Trust. The officer shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust it shall be the Chief Executive.

1.2.2 “Associate Member” means a person appointed to perform specific statutory and

non-statutory duties which have been delegated by the Trust Board for them to perform and these duties have been recorded in an appropriate Trust Board minute or other suitable record.

1.2.3 "Board" means the Chairman, officer (executive) and non-officer (non-executive)

members of the Trust collectively as a body. 1.2.4 "Budget" means a resource, expressed in financial terms, proposed by the Board

for the purpose of carrying out, for a specific period, any or all of the functions of the Trust.

1.2.5 “Budget Manager (Budget Holder)” means the director or employee with

delegated authority to manage finances (Income and Expenditure) for a specific area of the organisation.

1.2.6 "Chairman of the Board (or Trust)" is the person appointed by the Secretary of

State for Health to lead the Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression “the Chairman of the Trust” shall be deemed to include the Vice-Chairman of the Trust if the Chairman is absent from the meeting or is otherwise unavailable.

1.2.7 "Chief Executive" means the Chief Executive Officer of the Trust. 1.2.8 "Commissioning" means the process for determining the need for and for

obtaining the supply of healthcare and related services by the Trust within available resources.

1.2.9 "Committee" means a committee or sub-committee created and appointed by the

Board or by an authorized committee, group or officer. 1.2.10 "Committee members" means persons formally appointed by the Board or by an

authorized committee, group or officer to sit on or to chair specific committees. 1.2.11 "Contracting and procuring" means the systems for obtaining the supply of

goods, materials, manufactured items, services, building and engineering services,


works of construction and maintenance and for disposal of surplus and obsolete assets.

1.2.12 "Director of Finance and Procurement" means the Chief Financial Officer of the

Trust. 1.2.13 “Funds held on trust” shall mean those funds which the Trust holds on date of

incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under S.90 of the NHS Act 1977, as amended. Such funds may or may not be charitable.

1.2.14 "Member" means officer or non-officer member of the Board as the context

permits. Member in relation to the Board does not include its Chairman. 1.2.15 "Membership, Procedure and Administration Arrangements Regulations" means NHS Membership and Procedure Regulations (SI 1990/2024) and subsequent amendments. 1.2.16 "Nominated officer" means an officer charged with the responsibility for

discharging specific tasks within Standing Orders and Standing Financial Instructions.

1.2.17 "Non-officer member" means a member of the Trust who is not an officer of the

Trust and is not to be treated as an officer by virtue of regulation 1(3) of the Membership, Procedure and Administration Arrangements Regulations. Non-officer Board members are commonly called Non-executive Directors.

1.2.18 "Officer" means employee of the Trust or any other person holding a paid

appointment or office with the Trust. 1.2.19 "Officer member" means a member of the Trust who is either an officer of the Trust

or is to be treated as an officer by virtue of regulation 1(3) (i.e. the Chairman of the Trust or any person nominated by such a Committee for appointment as a Trust member). Officer Board members are commonly called Executive Directors.

1.2.20 “Quality Committee" means a committee of the Board whose functions are

concerned with the arrangements for assuring both the Trust‟s corporate governance and the quality of healthcare for which the Trust is responsible.

1.2.21 "Secretary" means a person appointed to act independently of the Board to

provide advice on corporate governance issues to the Board and the Chairman and monitor the Trust‟s compliance with the law, Standing Orders, and Department of Health guidance.

1.2.22 "SFIs" means Standing Financial Instructions. 1.2.23 "SOs" means Standing Orders. 1.2.24 “Trust” means the Oxford University Hospitals NHS Trust. 1.2.25 "Vice-Chairman" means the non-officer member appointed by the Board to take on

the Chairman‟s duties if the Chairman is absent for any reason.

2 Wherever the title Chief Executive, Director of Finance and Procurement or other nominated officer is used, it shall be deemed to include such other directors or employees who have been duly authorized to represent them. Wherever the term “officer” is used and the context permits it shall be deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust.


SECTION B – STANDING ORDERS

1. INTRODUCTION

1.1 Statutory Framework The Oxford University Hospitals NHS Trust (the Trust) is a statutory body which came into existence on 1

st November 2011 under The Oxford Radcliffe Hospitals National Health

Service Trust (Change of Name) (Establishment) Amendment Order 2011 No 2397 (the Establishment Order). (1) The principal place of business of the Trust is the John Radcliffe Hospital, Headley

Way, Headington, Oxford, OX3 9DZ. The Trust‟s other sites are the Churchill Hospital and the Nuffield Orthopaedic Centre in Oxford and the Horton General Hospital in Banbury.

(2) NHS Trusts are governed by Act of Parliament, mainly the National Health Service

Act 1977 (NHS Act 1977), the National Health Service and Community Care Act 1990 (NHS & CC Act 1990) as amended by the Health Authorities Act 1995 and the Health Act 1999 and the National Health Service Act 2006 (the NHS Act 2006).

(3) The functions of the Trust are conferred by this legislation. (4) [As a statutory body, the Trust has specified powers to contract in its own name] (5) The Trust also has statutory powers under Section 28A of the NHS Act 1977, as

amended by the Health Act 1999, to fund projects jointly planned with local authorities, voluntary organisations and other bodies.

(6) The Code of Accountability requires the Trust to adopt Standing Orders for the

regulation of its proceedings and business. The Trust must also adopt Standing Financial Instructions (SFIs) as an integral part of Standing Orders setting out the responsibilities of individuals.

(7) The Trust has adopted the Codes of Conduct and Accountability as required and

individual Board members confirm their adoption of these codes each year. (8) The Trust will also be bound by such other statutes and legal provisions which

govern the conduct of its affairs. 1.2 NHS Framework (1) In addition to the statutory requirements the Secretary of State through the

Department of Health issues further directions and guidance. These are normally issued under cover of a circular or letter.

(2) The Code of Accountability requires that, inter alia, Boards draw up a schedule of

decisions reserved to the Board, and ensure that management arrangements are in place to enable responsibility to be clearly delegated to senior executives (a scheme of delegation). The code also requires the establishment of audit and remuneration committees with formally agreed terms of reference. The Codes of Conduct makes various requirements concerning possible conflicts of interest of Board members.

(3) The Code of Practice on Openness in the NHS sets out the requirements for public

access to information on the NHS. In addition, the Trust has in place a publication scheme in response to the Freedom of Information Act, and systems to respond to requests made under the Act.


1.3 Delegation of Powers The Trust has powers to delegate and make arrangements for delegation. The

Standing Orders set out the detail of these arrangements. Under the Standing Order relating to the Arrangements for the Exercise of Functions (SO 5) the Trust is given powers to "make arrangements for the exercise, on behalf of the Trust of any of their functions by a committee, sub-committee or joint committee appointed by virtue of Standing Order 4 or by an officer of the Trust, in each case subject to such restrictions and conditions as the Trust thinks fit or as the Secretary of State may direct". Delegated Powers are covered in a separate document (Reservation of Powers to the Board and Delegation of Powers). (See Section 1.8 and Appendix 2 of the Corporate Governance Framework Manual.) This document has effect as if incorporated into the Standing Orders. Delegated Powers are covered in a separate document entitled – „Schedule of Matters reserved to the Board and Scheme of Delegation‟ and have effect as if incorporated into the Standing Orders and Standing Financial Instructions.

1.4 Integrated Governance Trust Boards are encouraged to develop integrated governance arrangements that

will lead to good governance and to ensure that decision-making is informed by intelligent information covering the full range of corporate, financial, clinical, information and research governance. Guidance from the Department of Health on the move toward and implementation of integrated governance has been issued and will be incorporated in the Trust‟s risk management strategy (see Integrated Governance Handbook 2006). Integrated governance will better enable the Board to take a holistic view of the organisation and its capacity to meet its legal and statutory requirements and its clinical, quality and financial objectives.

Return to Contents


2. THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF MEMBERS

2.1 Composition of the Membership of the Trust Board In accordance with the Membership, Procedure and Administration Arrangements

regulations the composition of the Board shall be: (1) The Chairman of the Trust (Appointed by the NHS Appointments Commission); (2) Up to 6 non-officer board members (appointed by the NHS Appointments

Commission); Nb Statutory Instrument 2000 No 961 authorised the appointment of a sixth non-officer Board member, by virtue of the Trust‟s size; most NHS Trusts may only have five.

(3) Up to 5 officer members (but not exceeding the number of non-officer

members) including:

the Chief Executive;

the Director of Finance and Procurement;

the Medical Director

the Chief Nurse

one further designated Executive Director. At present, this appointment is held by the Director of Planning and Information.

The Trust shall have not more than 12 and not less than 8 members (unless otherwise determined by the Secretary of State for Health and set out in the Trust‟s Establishment Order or such other communication from the Secretary of State).

(4) The Trust may from time to time appoint an associate Board member, permitted by

the Department of Health Model Standing Orders to perform specific statutory and non-statutory duties which have been delegated by the Trust Board for them to perform if these duties have been recorded in an appropriate Trust Board minute or other suitable record.

2.2 Appointment of Chairman and Members of the Trust

(1) Appointment of the Chairman and Members of the Trust - Paragraph 4 of Schedule 5A to the 1977 Act, as inserted by the Health Act 1999, provides that the Chairman is appointed by the Secretary of State, but otherwise the appointment and tenure of office of the Chairman and members are set out in the Membership, Procedure and Administration Arrangements Regulations. The hospitals referred to in part B section1.1.1 are hospitals which, in the opinion of the Secretary of State, have a significant teaching and research commitment and accordingly one of the non-executive directors shall be appointed from The University of Oxford.

2.3 Terms of Office of the Chairman and Members (1) The regulations setting out the period of tenure of office of the Chairman and

members and for the termination or suspension of office of the Chairman and members are contained in Sections 2 to 4 of the Membership, Procedure and Administration Arrangements and Administration Regulations.

2.4 Appointment and Powers of Vice-Chairman


(1) Subject to Standing Order 2.4 (2) below, the Chairman and members of the Trust may appoint one of their numbers, who is not also an officer member, to be Vice-Chairman, for such period, not exceeding the remainder of his term as a member of the Trust, as they may specify on appointing him.

(2) Any member so appointed may at any time resign from the office of Vice-Chairman

by giving notice in writing to the Chairman. The Chairman and members may thereupon appoint another member as Vice-Chairman in accordance with the provisions of Standing Order 2.4 (1).

(3) Where the Chairman of the Trust has died or has ceased to hold office, or where

they have been unable to perform their duties as Chairman owing to illness or any other cause, the Vice-Chairman shall act as Chairman until a new Chairman is appointed or the existing Chairman resumes their duties, as the case may be; and references to the Chairman in these Standing Orders shall, so long as there is no Chairman able to perform those duties, be taken to include references to the Vice-Chairman.

2.5 Joint Members a. Where more than one person is appointed jointly to a post mentioned in regulation

2(4)(a) of the Membership, Procedure and Administration Arrangements Regulations those persons shall count for the purpose of Standing Order 2.1 as one person.

b. Where the office of a member of the Board is shared jointly by more than one

person:

(a) either or both of those persons may attend or take part in meetings of the Board;

(b) if both are present at a meeting they should cast one vote if they

agree; (c) in the case of disagreements no vote should be cast; (d) the presence of either or both of those persons should count as the

presence of one person for the purposes of Standing Order 3.11 Quorum.

2.6 HealthWatch HealthWatch aims to ensure that local people come together with staff to highlight

the need for people–centred service changes at all levels of the health and care system. Local HealthWatch will also have an important focus on supporting the diverse needs of individuals, helping them to find the information they need so they can make the most of the wide range of choices available to them and, if necessary, the place to go to get help if they need to make a complaint.

2.7 Role of Members The Board will function as a corporate decision-making body, Officer and Non-

Officer Members will be full and equal members. Their role as members of the Trust Board will be to consider the key strategic and managerial issues facing the Trust in carrying out its statutory and other functions. All Board members have responsibility to challenge the decisions of the Board constructively, and to help develop proposals on strategy.

(1) Non-executive Members


Non-executive members have a particular duty to ensure that such challenge is made. They should scrutinize the performance of management in meetings, monitor agreed goals and objectives, and monitor the reporting of performance; and should satisfy themselves as to the integrity of financial, clinical and other information, and that financial and clinical quality, controls and systems of risk management are robust and defensible. The Non-Executive Members shall not be granted nor shall they seek to exercise any individual executive powers on behalf of the Trust. However they may exercise authority collectively when acting as members of the Board, or individually when chairing a committee of the Trust which has delegated powers. (2) Executive Members

Executive Members shall exercise their authority within the terms of these Standing

Orders and Standing Financial Instructions and the Scheme of Delegation. (3) Chief Executive The Chief Executive shall be responsible for the overall performance of the

executive functions of the Trust. He/she is the Accountable Officer for the Trust and shall be responsible for ensuring the discharge of obligations under Financial Directions and in line with the requirements of the Accountable Officer Memorandum for Trust Chief Executives.

(3) Director of Finance and Procurement The Director of Finance and Procurement shall be responsible for the provision of

financial advice to the Trust and to its members and for the supervision of financial control and accounting systems. He/she shall be responsible along with the Chief Executive for ensuring the discharge of obligations under relevant Financial Directions.

(4) Chairman The Chairman shall be responsible for the operation of the Board and chair all

Board meetings when present. The Chairman has certain delegated executive powers. The Chairman must comply with the terms of appointment and with these Standing Orders.

The Chairman shall liaise with the NHS Appointments Commission over the

appointment of Non-Executive Directors and once appointed shall take responsibility either directly or indirectly for their induction, their portfolios of interests and assignments, and their performance.

The Chairman shall work in close harmony with the Chief Executive and shall

ensure that key and appropriate issues are discussed by the Board in a timely manner with all the necessary information and advice being made available to the Board to inform the debate and ultimate resolutions.

2.8 Corporate role of the Board (1) All business shall be conducted in the name of the Trust. (2) The powers of the Trust established under statute shall be exercised by the Board

meeting in public session except as otherwise provided for in Standing Order No. 3. (3) The Board shall define and regularly review the functions it exercises on behalf of

the Secretary of State.


2.9 Schedule of Matters reserved to the Board and Scheme of Delegation (1) The Board has resolved that certain powers and decisions may only be exercised

by the Board in formal session. These powers and decisions are set out in the „Schedule of Matters Reserved to the Board‟ and shall have effect as if incorporated into the Standing Orders. Those powers which it has delegated to officers and other bodies are contained in the Scheme of Delegation.

2.10 Lead Roles for Board Members The Chairman will ensure that the designation of Lead roles or appointments of

Board members as required by the Department of Health or as set out in any statutory or other guidance will be made in accordance with that guidance or statutory requirement (e.g. appointing a Lead Board Member with responsibilities for Infection Control or Child Protection Services etc.).

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3. MEETINGS OF THE TRUST 3.1 Calling meetings (1) The Board shall meet sufficiently regularly to discharge its duties effectively. It is

anticipated that the Board will meet in public and in private throughout the year. (2) Ordinary meetings of the Board shall be held at regular intervals at such times and

places as the Board may determine. (3) The Chairman of the Trust may call a meeting of the Board at any time. (4) One third or more members of the Board may requisition a meeting in writing. If the

Chairman refuses, or fails, to call a meeting within seven days of a requisition being presented, the members signing the requisition may forthwith call a meeting.

3.2 Notice of Meetings and the Business to be transacted (1) Before each meeting of the Board a written notice specifying the business proposed

to be transacted shall be delivered to every member, or sent by post to the usual place of residence of each member, so as to be available to members at least three clear days before the meeting. The notice shall be signed by the Chairman or by an officer authorised by the Chairman to sign on their behalf. Want of service of such a notice on any member shall not affect the validity of a meeting.

(2) In the case of a meeting called by members in default of the Chairman calling the

meeting, the notice shall be signed by those members. (3) No business shall be transacted at the meeting other than that specified on the

agenda, or emergency motions allowed under Standing Order 3.6. (4) A member desiring a matter to be included on an agenda shall make his/her request

in writing to the Chairman at least 10 clear days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 10 days before a meeting may be included on the agenda at the discretion of the Chairman.

(5) Before each meeting of the Board a public notice of the time and place of the

meeting, and the public part of the agenda, shall be displayed at the Trust‟s principal offices at least three clear days before the meeting, (required by the Public Bodies (Admission to Meetings) Act 1960 Section 1 (4) (a)).

3.3 Agenda and Supporting Papers The Agenda will be sent to members at least 3 days before the meeting and

supporting papers, whenever possible, shall accompany the agenda, but will certainly be dispatched no later than three clear days before the meeting, save in emergency.

3.4 Petitions Where a petition has been received by the Trust the Chairman shall include the

petition as an item for the agenda of the next meeting. 3.5 Notice of Motion


(1) Subject to the provision of Standing Orders 3.7 „Motions: Procedure at and during a meeting‟ and 3.8 „Motions to rescind a resolution‟, a member of the Board wishing to move a motion shall send a written notice to the Chief Executive who will ensure that it is brought to the immediate attention of the Chairman.

(2) The notice shall be delivered at least 10 clear days before the meeting. The Chief

Executive shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting.

3.6 Emergency Motions Subject to the agreement of the Chairman, and subject also to the provision of

Standing Order 3.7 „Motions: Procedure at and during a meeting‟, a member of the Board may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Trust Board at the commencement of the business of the meeting as an additional item included in the agenda. The Chairman's decision to include the item shall be final.

3.7 Motions: Procedure at and during a meeting i) Who may propose A motion may be proposed by the Chairman of the meeting or any member present.

It must also be seconded by another member. ii) Contents of motions The Chairman may exclude from the debate at their discretion any such motion of

which notice was not given on the notice summoning the meeting other than a motion relating to:

- the reception of a report; - consideration of any item of business before the Trust Board; - the accuracy of minutes; - that the Board proceed to next business; - that the Board adjourn; - that the question be now put. iii) Amendments to motions A motion for amendment shall not be discussed unless it has been proposed and

seconded. Amendments to motions shall be moved relevant to the motion, and shall not have

the effect of negating the motion before the Board. If there are a number of amendments, they shall be considered one at a time.

When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved.

iv) Rights of reply to motions a) Amendments


The mover of an amendment may reply to the debate on their amendment immediately prior to the mover of the original motion, who shall have the right of reply at the close of debate on the amendment, but may not otherwise speak on it.

b) Substantive/original motion The member who proposed the substantive motion shall have a right of reply at the

close of any debate on the motion. v) Withdrawing a motion A motion, or an amendment to a motion, may be withdrawn. vi) Motions once under debate When a motion is under debate, no motion may be moved other than:

- an amendment to the motion; - the adjournment of the discussion, or the meeting; - that the meeting proceed to the next business; - that the question should be now put; - the appointment of an 'ad hoc' committee to deal with a specific

item of business; - that a member/director be not further heard; - a motion under Section l (2) or Section l (8) of the Public Bodies

(Admissions to Meetings) Act l960 resolving to exclude the public, including the press (see Standing Order 3.17).

In those cases where the motion is either that the meeting proceeds to the „next

business‟ or „that the question be now put‟ in the interests of objectivity these should only be put forward by a member of the Board who has not taken part in the debate and who is eligible to vote.

If a motion to proceed to the next business or that the question be now put, is

carried, the Chairman should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote.

3.8 Motion to Rescind a Resolution (1) Notice of motion to rescind any resolution (or the general substance of any

resolution) which has been passed within the preceding six calendar months shall bear the signature of the member who gives it and also the signature of three other members, and before considering any such motion of which notice shall have been given, the Trust Board may refer the matter to any appropriate Committee or the Chief Executive for recommendation.

(2) When any such motion has been dealt with by the Trust Board it shall not be

competent for any director/member other than the Chairman to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Chief Executive.

3.9 Chairman of meeting (1) At any meeting of the Trust Board the Chairman, if present, shall preside. If

the Chairman is absent from the meeting, the Vice-Chairman (if the Board has appointed one), if present, shall preside.


(2) If the Chairman and Vice-Chairman are absent, such member (who is not also an Officer Member of the Trust) as the members present shall choose shall preside.

3.10 Chairman's ruling The decision of the Chairman of the meeting on questions of order, relevancy and

regularity (including procedure on handling motions) and their interpretation of the Standing Orders and Standing Financial Instructions, at the meeting, shall be final.

3.11 Quorum (i) No business shall be transacted at a meeting unless at least one-third of the

whole number of the Chairman and members (including at least one member who is also an Officer Member of the Trust and one member who is not) is present.

(ii) An Officer in attendance for an Executive Director (Officer Member) but without

formal acting up status may not count towards the quorum. (iii) If the Chairman or member has been disqualified from participating in the

discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest (see SO No.7) that person shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business. The above requirement for at least one officer member to form part of the quorum shall not apply where the officer members are excluded from a meeting (for example when the Board considers the recommendations of the Remuneration and Appointments Committee]

3.12 Voting (i) Save as provided in Standing Orders 3.l3 - Suspension of Standing Orders

and 3.l4 - Variation and Amendment of Standing Orders, every question put to a vote at a meeting shall be determined by a majority of the votes of members present and voting on the question. In the case of an equal vote, the person presiding (i.e.: the Chairman of the meeting shall have a second, and casting vote.

(ii) At the discretion of the Chairman all questions put to the vote shall be

determined by oral expression or by a show of hands, unless the Chairman directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot.

(iii) If at least one third of the members present so request, the voting on any

question may be recorded so as to show how each member present voted or did not vote (except when conducted by paper ballot).

(iv) If a member so requests, their vote shall be recorded by name. (v) In no circumstances may an absent member vote by proxy. Absence is

defined as being absent at the time of the vote. (vi) A manager who has been formally appointed to act up for an Officer Member

during a period of incapacity or temporarily to fill an Executive Director vacancy shall be entitled to exercise the voting rights of the Officer Member.


(vii) A manager attending the Trust Board meeting to represent an Officer Member during a period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the Officer Member. An Officer‟s status when attending a meeting shall be recorded in the minutes.

(viii) For the voting rules relating to joint members see Standing Order 2.5. 3.13 Suspension of Standing Orders (i) Except where this would contravene any statutory provision or any direction

made by the Secretary of State or the rules relating to the Quorum (SO 3.11), any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the whole number of the members of the Board are present (including at least one member who is an Officer Member of the Trust and one member who is not) and that at least two-thirds of those members present signify their agreement to such suspension. The reason for the suspension shall be recorded in the Trust Board's minutes.

(ii) A separate record of matters discussed during the suspension of Standing

Orders shall be made and shall be available to the Chairman and members of the Trust.

(iii) No formal business may be transacted while Standing Orders are

suspended. (iv) A decision to suspend Standing Orders shall be recorded in the minutes of

the meeting.

(v) The Audit and Finance Committee shall review every decision to suspend Standing Orders.

(vi) The Board shall receive a report each year on each suspension of Standing

Orders, including a report that no suspensions took place during the relevant year.

3.14 Variation and amendment of Standing Orders These Standing Orders shall not be varied except in the following circumstances: - upon a notice of motion under Standing Order 3.5; - upon a recommendation of the Chairman or Chief Executive included on the

agenda for the meeting; - that two thirds of the Board members are present at the meeting where the

variation or amendment is being discussed, and that at least half of the Trust‟s Non-Officer members vote in favour of the amendment;

- providing that any variation or amendment does not contravene a statutory provision or direction made by the Secretary of State.

3.15 Record of Attendance The names of the Chairman and Directors/members present at the meeting shall be

recorded. In line with the NHS Litigation Authority‟s Risk Management Standard 1.3 all members must attend at least 50% of the meetings held in any 12 month period.

3.16 Minutes The minutes of the proceedings of a meeting shall be drawn up and submitted for

agreement at the next ensuing meeting where they shall be signed by the person presiding at it.


No discussion shall take place upon the minutes except upon their accuracy or where the Chairman considers discussion appropriate.

3.17 Admission of public and the press (i) Admission and exclusion on grounds of confidentiality of business to

be transacted The public and representatives of the press may attend all meetings of the

Trust, but shall be required to withdraw upon the Trust Board resolving as follows:

- 'that representatives of the press, and other members of the public, be

excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', Section 1 (2), Public Bodies (Admission to Meetings) Act l960

- Guidance should be sought from the NHS Trust’s Freedom of Information

Lead to ensure correct procedure is followed on matters to be included in the exclusion.

(ii) General disturbances The Chairman (or Vice-Chairman if one has been appointed) or the person

presiding over the meeting shall give such directions as he thinks fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Trust‟s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted, the public will be required to withdraw upon the Trust Board resolving as follows:

- `That in the interests of public order the meeting adjourn for (the period to

be specified) to enable the Trust Board to complete its business without the presence of the public'. Section 1(8) Public Bodies (Admissions to Meetings) Act l960.

(iii) Business proposed to be transacted when the press and public have

been excluded from a meeting Matters to be dealt with by the Trust Board following the exclusion of

representatives of the press, and other members of the public, as provided in (i) and (ii) above, shall be confidential to the members of the Board.

Members and Officers or any employee of the Trust in attendance shall not

reveal or disclose the contents of papers marked 'In Confidence' or minutes headed 'Items Taken in Private' outside of the Trust, without the express permission of the Trust. This prohibition shall apply equally to the content of any discussion during the Board meeting which may take place on such reports or papers.

(iv) Use of Mechanical or Electrical Equipment for Recording or

Transmission of Meetings Nothing in these Standing Orders shall be construed as permitting the

introduction by the public, or press representatives, of recording, transmitting, video or similar apparatus into meetings of the Trust or Committee thereof. Such permission shall be granted only upon resolution of the Trust.


3.18 Observers at Trust meetings The Trust will decide what arrangements and terms and conditions it feels are

appropriate to offer in extending an invitation to observers to attend and address any of the Trust Board's meetings and may change, alter or vary these terms and conditions as it deems fit.

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4. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES 4.1 Appointment of Committees

Subject to such directions as may be given by the Secretary of State for Health, the Trust Board may appoint committees of the Trust.

The Trust shall determine the membership and terms of reference of committees

and sub-committees and shall if it requires to, receive and consider reports of such committees.

4.2 Joint Committees

(i) Joint committees may be appointed by the Trust by joining together with one

or more other Strategic Health Authorities, or other Trusts consisting of, wholly or partly of the Chairman and members of the Trust or other health service bodies, or wholly of persons who are not members of the Trust or other health bodies in question.

(ii) Any committee or joint committee appointed under this Standing Order may,

subject to such directions as may be given by the Secretary of State or the Trust or other health bodies in question, appoint sub-committees consisting wholly or partly of members of the committees or joint committee (whether or not they are members of the Trust or health bodies in question) or wholly of persons who are not members of the Trust or health bodies in question or the committee of the Trust or health bodies in question.

4.3 Applicability of Standing Orders and Standing Financial Instructions to

Committees The Standing Orders and Standing Financial Instructions of the Trust, as far as they

are applicable, shall as appropriate apply to meetings and any committees established by the Trust. In which case the term “Chairman” is to be read as a reference to the Chairman of other committee as the context permits, and the term “member” is to be read as a reference to a member of other committee also as the context permits. (There is no requirement to hold meetings of committees established by the Trust in public, but the chair of each such committee shall present a report of each of its meetings to a public meeting of the Board.)

4.4 Terms of Reference Each such committee shall have such terms of reference and powers and be

subject to such conditions (as to reporting back to the Board), as the Board shall decide and shall be in accordance with any legislation and regulation or direction issued by the Secretary of State. Such terms of reference shall have effect as if incorporated into the Standing Orders.

4.5 Delegation of powers by Committees to Sub-Committees Where committees are authorised to establish sub-committees they may not

delegate executive powers to the sub-committee unless expressly authorised by the Trust Board.

4.6 Approval of Appointments to Committees The Board shall approve the appointments to each of the committees which it has

formally constituted. Where the Board determines, and regulations permit, that persons, who are neither members nor officers, shall be appointed to a committee the terms of such appointment shall be within the powers of the Board as defined by


the Secretary of State. The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses in accordance where appropriate with national guidance.

4.7 Appointments for Statutory functions Where the Board is required to appoint persons to a committee and/or to undertake

statutory functions as required by the Secretary of State, and where such appointments are to operate independently of the Board such appointment shall be made in accordance with the regulations and directions made by the Secretary of State.

4.8 Committees established by the Trust Board The committees, sub-committees, and joint-committees established by the Board

are:

4.8.1 Audit and Finance Committee

In line with the requirements of the NHS Audit Committee Handbook, NHS Codes of

Conduct and Accountability, the Monitor Code of Governance and Monitor‟s Audit Code for Foundation Trusts, an Audit and Finance Committee will be established and is responsible for providing assurance to the Trust Board on the Trust‟s system of internal control by means of independent and objective review of financial and corporate governance, and risk management arrangements, including compliance with laws, guidance, and regulations governing the NHS. The Terms of Reference will be approved by the Trust Board and reviewed on a periodic basis.

The Committee shall work closely with the Quality Committee on relevant matters, to develop integrated governance, including assurance on systems for risk and safety and shall do so through mechanisms including common membership of both Committees The Committee shall comprise exclusively three non-officer Board members, At least one of the Non-executive Directors should have recent and relevant financial experience. The Chairman of the Board shall not be a member of the Audit and Finance Committee.

4.8.2 Remuneration and Appointments Committee (R & A) In line with the requirements of the NHS Codes of Conduct and Accountability, and

the Monitor Code of Governance a Remuneration and Appointments Committee will be established and constituted.

The committee shall be comprised exclusively of all the Non-Executive Directors.

The Chairman of the Committee shall be elected by the Committee. The Chief Executive may be asked to attend meetings (or part of meetings) at which the appointment, remuneration and terms of service of Executive Directors (other than the Chief Executive) are under consideration. .

The Remuneration & Appointments Committee is responsible for determining the policy on executive remuneration, approving contracts of employment for executives & agreeing arrangements for termination of contracts.

4.8.3 Quality Committee

The Quality Committee is responsible for providing the Trust Board with assurance on all aspects of quality of clinical care; governance systems, including the management of risk, for clinical, corporate, HR, information and Research and


Development issues; and regulatory standards of quality and safety. The membership of the committee shall be composed of three Non-executive Directors as core members, along with three Executive Directors (Chief Executive; Medical Director and Chief Nurse) and two other senior officers. It shall share cross-membership with the Audit and Finance Committee to promote integrated governance. Inter alia it shall:-

1 Oversee and maintain an effective system for safety within the Trust, with particular focus on; patient safety, staff safety and wider heath & safety requirements.

2 Oversee and maintain an effective system for delivering a high quality experience for all its patients and users, with particular focus on involvement and engagement for the purposes of learning and making improvement.

3 Oversee and maintain an effective system for monitoring clinical outcomes

and clinical effectiveness, with particular focus on ensuring patients receive the best possible outcomes of care across the full range of Trust activities.

4 Ensure the Trust maintains compliance with the Care Quality Commission registration via assurance of the systems of control, with particular emphasis on the 16 standards of safety & quality.

5 Be responsible for the oversight and assurance of statutory and mandatory requirements, relating to quality of care.

6 Be responsible for the oversight and assurance of external assessment systems (such as NHSLA Risk Management Standards), professional bodies‟ and regulatory bodies‟ requirements.

7 Monitor and review the system for Human Resources Governance, ensuring that the Board is assured of continued compliance through regular reporting.

8 Monitor and review the system for Information Governance, ensuring that the Board is assured of continued compliance through regular reporting.

9 Monitor and review the system for Research & Development Governance, ensuring that the Board is assured of continued compliance through regular reporting.

10 Undertake any other duties as delegated by the Trust Board

4.8.4 Board in Committee

The Board in Committee provides the Trust Board with an opportunity to consider specific aspects of strategy, to develop and maintain the Board‟s education and development, to gain greater knowledge and understanding of the patient experiences through sharing of information on good & poor practice in the context of overall services; and to facilitate informal exchange of NED experiences. All Trust Board members are full members of the Board in Committee.

4.8.5 Trust Management Executive

The Trust Management Executive (TME) will provide the executive management of the Trust and will oversee the development and implementation of the Trust‟s service strategy within the parameters established by the Trust Board. It will also closely monitor standards of care, quality and safety and monitor and mitigate risk. It will agree all policies other than those retained by the Trust Board.


4.8.6 Other Committees The Board may also establish such other committees as required to discharge the

Trust's responsibilities. The terms of reference of Board Committees are set out in section C

.

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5. ARRANGEMENTS FOR THE EXERCISE OF TRUST FUNCTIONS BY DELEGATION

5.1 Delegation of Functions to Committees, Officers or other bodies 5.1.1 Subject to such directions as may be given by the Secretary of State, the Board

may make arrangements for the exercise, on behalf of the Board, of any of its functions by a committee, sub-committee appointed by virtue of Standing Order 4, or by an officer of the Trust, or by another body as defined in Standing Order 5.1.2 below, in each case subject to such restrictions and conditions as the Trust thinks fit.

5.1.2 Section 16B of the NHS Act 1977 allows for regulations to provide for the functions

of Trust‟s to be carried out by third parties. In accordance with The Trusts (Membership, Procedure and Administration Arrangements) Regulations 2000 the functions of the Trust may also be carried out in the following ways:

(i) by another Trust; (ii) jointly with any one or more of the following: NHS trusts, Strategic Health

Authorities or PCTs; (iii) by arrangement with the appropriate Trust or PCT, by a joint committee or joint sub-

committee of the Trust and one or more other health service bodies; (iv) in relation to arrangements made under S63(1) of the Health Services and Public

Health Act 1968, jointly with one or more Strategic Health Authorities, SHAs, NHS Trusts or PCT.

5.1.3 Where a function is delegated by these Regulations to another Trust, then that Trust

or health service body exercises the function in its own right; the receiving Trust has responsibility to ensure that the proper delegation of the function is in place. In other situations, i.e. delegation to committees, sub-committees or officers, the Trust delegating the function retains full responsibility.

5.2 Emergency Powers and urgent decisions The powers which the Board has reserved to itself within these Standing Orders

(see Standing Order 2.9) may in emergency or for an urgent decision be exercised by the Chief Executive and the Chairman after having consulted at least two non-officer members. The exercise of such powers by the Chief Executive and Chairman shall be reported to the next formal meeting of the Trust Board in public session for formal ratification.

5.3 Delegation to Committees 5.3.1 The Board shall agree from time to time to the delegation of executive powers to be

exercised by other committees, or sub-committees, or joint-committees, which it has formally constituted in accordance with directions issued by the Secretary of State. The constitution and terms of reference of these committees, or sub-committees, or joint committees, and their specific executive powers shall be approved by the Board in respect of its sub-committees.

5.3.2 When the Board is not meeting as the Trust in public session it shall operate as a

committee and may only exercise such powers as may have been delegated to it by the Trust in public session.


5.4 Delegation to Officers 5.4.1 Those functions of the Trust which have not been retained as reserved by the Board

or delegated to other committee or sub-committee or joint-committee shall be exercised on behalf of the Trust by the Chief Executive. The Chief Executive shall determine which functions he/she will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain accountability to the Trust.

5.4.2 The Chief Executive shall prepare a Scheme of Delegation identifying his/her

proposals which shall be considered and approved by the Board. The Chief Executive may periodically propose amendment to the Scheme of Delegation which shall be considered and approved by the Board.

5.4.3 Nothing in the Scheme of Delegation shall impair the discharge of the direct

accountability to the Board of the Director of Finance and Procurement to provide information and advise the Board in accordance with statutory or Department of Health requirements. Outside these statutory requirements the role of the Director of Finance and Procurement shall be accountable to the Chief Executive for operational matters.

5.5 Schedule of Matters Reserved to the Trust and Scheme of Delegation of

powers 5.5.1 The arrangements made by the Board as set out in the "Schedule of Matters

Reserved to the Board” and “Scheme of Delegation” of powers shall have effect as if incorporated in these Standing Orders.

5.6 Duty to report non-compliance with Standing Orders and Standing Financial

Instructions If for any reason these Standing Orders are not complied with, full details of the

non-compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Board for action or ratification. All members of the Trust Board and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Executive as soon as possible.

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6. OVERLAP WITH OTHER TRUST POLICY

STATEMENTS/PROCEDURES, REGULATIONS AND THE STANDING FINANCIAL INSTRUCTIONS

6.1 Policy statements: general principles The Trust Board will from time to time agree and approve Policy statements/

procedures which will apply to all or specific groups of staff employed by Oxford University Hospitals NHS Trust. The decisions to approve such policies and procedures will be recorded in an appropriate Trust Board minute and will be deemed where appropriate to be an integral part of the Trust's Standing Orders and Standing Financial Instructions. A list of policies and procedures will be maintained and reviewed annually.

6.2 Specific Policy statements Notwithstanding the application of SO 6.1 above, these Standing Orders and

Standing Financial Instructions must be read in conjunction with the following Policy statements:

- the Standards of Business Conduct and Conflicts of Interest Policy for the

staff of Oxford University Hospitals NHS Trust staff; - The Performance and Conduct Procedures adopted by the Board - the staff Disciplinary and Appeals Procedures adopted by the Trust

each of which shall have effect as if incorporated in these Standing Orders. 6.3 Standing Financial Instructions Standing Financial Instructions adopted by the Trust Board in accordance with the

Financial Regulations shall have effect as if incorporated in these Standing Orders. 6.4 Specific guidance Notwithstanding the application of SO 6.1 above, these Standing Orders and

Standing Financial Instructions must be read in conjunction with the following guidance and any other issued by the Secretary of State for Health:

- Caldicott Guardian 1997; - Human Rights Act 1998;

- Freedom of Information Act 2000. - Bribery Act 2010

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7. DUTIES AND OBLIGATIONS OF BOARD MEMBERS/DIRECTORS AND SENIOR MANAGERS UNDER THESE STANDING ORDERS

7.1 Declaration of Interests

7.1.1 Requirements for Declaring Interests and applicability to Board Members i) The NHS Code of Accountability requires Trust Board Members to declare

interests which are relevant and material to the NHS Board of which they are a member. All existing Board members should declare such interests annually and as arising. Any Board members appointed subsequently should do so on appointment. At the start of each meeting of the Trust Board, all members shall declare against each item on the agenda, any interests which reasonably may be perceived as relevant and material.

7.1.2 Interests which are relevant and material (i) Interests which should be regarded as "relevant and material" are: a) Directorships, including Non-Executive Directorships held in

private companies or PLCs (with the exception of those of dormant companies);

b) Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS;

c) Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS;

d) A position of Authority in a charity or voluntary organisation in the field of health and social care;

e) Any connection with a voluntary or other organisation contracting for NHS services;

f) Research funding/grants that may be received by an individual or their department;

g) Interests in pooled funds that are under separate management.

(ii) Any member of the Trust Board who comes to know that the Trust has entered into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in Standing Order 7.3 below and elsewhere) has any pecuniary interest, direct or indirect, the Board member shall declare his/her interest by giving notice in writing of such fact to the Trust as soon as practicable.

7.1.3 Advice on Interests If Board members have any doubt about the relevance of an interest, this

should be discussed with the Chairman of the Trust or with the Board Secretary.

International Accounting Standard No 24 (issued by the International Accounting

Standards Board (IASB)) sets out the rules on the disclosure of related parties and defines when such relationships exist. In considering the issue, influence rather than the immediacy of the relationship is more important in assessing the relevance of an interest. The interests of partners in professional partnerships including general practitioners should also be considered.


7.1.4 Recording of Interests in Trust Board minutes At the time Board members' interests are declared (or as soon as practicable

thereafter), they should be recorded in the Trust Board minutes. Any changes in interests should be declared at the next Trust Board meeting

(whether or not that meeting is public) following the change occurring and recorded in the minutes of that meeting.

7.1.5 Publication of declared interests in Annual Report Board members' directorships of companies likely or possibly seeking to do

business with the NHS should be published in the Trust's annual report. The information should be kept up to date for inclusion in succeeding annual reports.

7.1.6 Conflicts of interest which arise during the course of a meeting During the course of a Trust Board meeting or of a Board Committee, if a conflict of

interest is established, the Board member concerned shall state the interest, should withdraw from the meeting and play no part in the relevant discussion or decision. (See overlap with SO 7.3)

7.2 Register of Interests

7.2.1 The Chief Executive will ensure that a Register of Interests is established to record

formally declarations of interests of Board or Committee members. In particular the Register will include details of all directorships and other relevant and material interests (as defined in SO 7.1.2) which have been declared by both executive and non-executive Trust Board members.

7.2.2. These details will be kept up to date by means of an annual review of the Register in

which any changes to interests declared during the preceding twelve months will be incorporated.

7.2.3 The Register will be available to the public and the Chief Executive will take

reasonable steps to bring the existence of the Register to the attention of local residents and to publicise arrangements for viewing it.

7.3 Exclusion of Chairman and Members in proceedings on account of pecuniary

interest 7.3.1 Definition of terms used in interpreting „Pecuniary‟ interest For the sake of clarity, the following definition of terms is to be used in interpreting

this Standing Order: (i) "spouse" shall include any person who lives with another person in the same

household (and any pecuniary interest of one spouse shall, if known to the other spouse, be deemed to be an interest of that other spouse);

(ii) "contract" shall include any proposed contract or other course of dealing. (iii) “Pecuniary interest” Subject to the exceptions set out in this Standing Order, a person shall be

treated as having an indirect pecuniary interest in a contract if:-


a) he/she, or a nominee of his/her, is a member of a company or other body (not being a public body), with which the contract is made, or to be made or which has a direct pecuniary interest in the same, or

b) he/she is a partner, associate or employee of any person with whom

the contract is made or to be made or who has a direct pecuniary interest in the same.

iv) Exception to Pecuniary interests A person shall not be regarded as having a pecuniary interest in any contract

if:- a) neither he/she or any person connected with him/her has any

beneficial interest in the securities of a company of which he/she or such person appears as a member, or

b) any interest that he/she or any person connected with him/her may

have in the contract is so remote or insignificant that it cannot reasonably be regarded as likely to influence him/her in relation to considering or voting on that contract, or

c) those securities of any company in which he/she (or any person

connected with him/her) has a beneficial interest do not exceed £5,000 in nominal value or one per cent of the total issued share capital of the company or of the relevant class of such capital, whichever is the less.

Provided however, that where paragraph (c) above applies the person shall

nevertheless be obliged to disclose/declare their interest in accordance with Standing Order 7.1.2 (ii).

7.3.2 Exclusion in proceedings of the Trust Board (i) Subject to the following provisions of this Standing Order, if the Chairman or

a member of the Trust Board has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Trust Board at which the contract or other matter is the subject of consideration, they shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

(ii) The Secretary of State may, subject to such conditions as he/she may think

fit to impose, remove any disability imposed by this Standing Order in any case in which it appears to him/her in the interests of the National Health Service that the disability should be removed. (See SO 7.3.3 on the „Waiver‟ which has been approved by the Secretary of State for Health).

(iii) The Trust Board may exclude the Chairman or a member of the Board from a

meeting of the Board while any contract, proposed contract or other matter in which he/she has a pecuniary interest is under consideration.

(iv) Any remuneration, compensation or allowance payable to the Chairman or a

Member by virtue of paragraph 11 of Schedule 5A to the National Health Service Act 1977 (pay and allowances) shall not be treated as a pecuniary interest for the purpose of this Standing Order.

(v) This Standing Order applies to a committee or sub-committee and to a joint

committee or sub-committee as it applies to the Trust and applies to a


member of any such committee or sub-committee (whether or not he/she is also a member of the Trust) as it applies to a member of the Trust.

7.3.3 Waiver of Standing Orders made by the Secretary of State for Health

(1) Power of the Secretary of State to make waivers Under regulation 11(2) of the NHS (Membership and Procedure Regulations SI

1999/2024 (“the Regulations”), there is a power for the Secretary of State to issue waivers if it appears to the Secretary of State in the interests of the health service that the disability in regulation 11 (which prevents a chairman or a member from taking part in the consideration or discussion of, or voting on any question with respect to, a matter in which he has a pecuniary interest) is removed. A waiver has been agreed in line with sub-sections (2) to (4) below.

(2) Definition of „Chairman‟ for the purpose of interpreting this waiver

For the purposes of paragraph 7.3.3. (3) (below), the “relevant chairman” is –

(a) at a meeting of the Trust, the Chairman of that Trust; (b) at a meeting of a Committee –

(i) in a case where the member in question is the Chairman of that Committee, the Chairman of the Trust;

(ii) in the case of any other member, the Chairman of that

Committee. (3) Application of waiver A waiver will apply in relation to the disability to participate in the proceedings of the

Trust on account of a pecuniary interest. It will apply to: (i) A member of the Oxford University Hospitals NHS Trust (“the Trust”), who is

a healthcare professional, within the meaning of regulation 5(5) of the Regulations, and who is providing or performing, or assisting in the provision or performance, of –

(a) services under the National Health Service Act 1977; or (b) services in connection with a pilot scheme under the National Health

Service Act 1997; for the benefit of persons for whom the Trust is responsible. (ii) Where the „pecuniary interest‟ of the member in the matter which is the

subject of consideration at a meeting at which he is present:-

(a) arises by reason only of the member‟s role as such a professional providing or performing, or assisting in the provision or performance of, those services to those persons;

(b) has been declared by the relevant chairman as an interest which

cannot reasonably be regarded as an interest more substantial than that of the majority of other persons who:–


(i) are members of the same profession as the member in question,

(ii) are providing or performing, or assisting in the provision or

performance of, such of those services as he provides or performs, or assists in the provision or performance of, for the benefit of persons for whom the Trust is responsible.

(4) Conditions which apply to the waiver and the removal of having a pecuniary

interest The removal is subject to the following conditions: (a) the member must disclose his/her interest as soon as practicable after the

commencement of the meeting and this must be recorded in the minutes; (b) the relevant chairman must consult the Chief Executive before making a

declaration in relation to the member in question pursuant to paragraph 7.3.3 (2) (b) above, except where that member is the Chief Executive;

(c) in the case of a meeting of the Trust: (i) the member may take part in the consideration or discussion of the

matter which must be subjected to a vote and the outcome recorded; (ii) may not vote on any question with respect to it. (d) in the case of a meeting of the Committee:

(i) the member may take part in the consideration or discussion of the

matter which must be subjected to a vote and the outcome recorded; (ii) may vote on any question with respect to it; but (iii) the resolution which is subject to the vote must comprise a

recommendation to, and be referred for approval by, the Trust Board. 7.4 Standards of Business Conduct 7.4.1 Trust Policy and National Guidance All Trust staff and members of must comply with the provisions of the Bribery Act

2010 and the Trust‟s Standards of Business Conduct and Conflicts of Interest Policy and the national guidance contained in HSG(93)5 on „Standards of Business Conduct for NHS staff‟ (see SO 6.2). These incorporate the Nolan Principles. All Trust staff shall make declarations of interests, gifts, hospitality and sponsorship as described above for Trust Board members. The declarations shall be included within the public register. Advice on interests can be sought as described above.

7.4.2 Interest of Officers in Contracts i) Any officer or employee of the Trust who comes to know that the Trust has

entered into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in SO 7.3) has any pecuniary interest, direct or indirect, the Officer shall declare their interest by giving notice in writing of such fact to the Chief Executive or Board Secretary as soon as practicable.

ii) An Officer should also declare to the Chief Executive any other employment

or business or other relationship of his/her, or of a cohabiting spouse, that


conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

iii) The Trust will require interests, employment or relationships so declared to

be entered in a register of interests of staff. 7.4.3 Canvassing of and Recommendations by Members in Relation to

Appointments i) Canvassing of members of the Trust or of any Committee of the Trust directly

or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

ii) Members of the Trust Board and Trust staff shall not solicit for any person

any appointment under the Trust or recommend any person for such appointment; but this paragraph of this Standing Order shall not preclude a member from giving written testimonial of a candidate‟s ability, experience or character for submission to the Trust.

7.4.4 Relatives of Members or Officers i) Candidates for any staff appointment under the Trust shall, when making an

application, disclose in writing to the Trust whether they are related to any member or the holder of any office under the Trust. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him liable to instant dismissal.

ii) The Chairman and every member and officer of the Trust shall disclose to the

Trust Board any relationship between himself and a candidate of whose candidature that member or officer is aware. It shall be the duty of the Chief Executive to report to the Trust Board any such disclosure made.

iii) On appointment, members (and prior to acceptance of an appointment in the

case of Executive Directors) should disclose to the Trust whether they are related to any other member or holder of any office under the Trust.

iv) Where the relationship to a member of the Trust is disclosed, the Standing

Order headed „Disability of Chairman and members in proceedings on account of pecuniary interest‟ (SO 7) shall apply.

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8. CUSTODY OF SEAL, SEALING OF DOCUMENTS AND SIGNATURE OF DOCUMENTS

8.1 Custody of Seal The common seal of the Trust shall be kept in a secure place by the Board

Secretary on behalf of the Chief Executive. 8.2 Sealing of Documents

8.2.1 All Sealings and Signings shall normally be undertaken by the Chairman and the Chief Executive. The Chairman may delegate this responsibility to any non-officer Board member, and the Chief Executive may delegate this responsibility to any officer Board member. Only the signatures of two officer Board members are required in the case of documents requiring only signing e.g. standard short term tenancy agreements or tenancies at will.

8.2.2 Where it is necessary that a document shall be sealed, the seal shall be affixed

in the presence of the Chairman (or other authorised Director of the Trust) and of the Chief Executive or Director of Finance and Procurement, or other officer deputising for the Chief Executive, and it shall be duly attested by them. The Board Secretary shall arrange for sealings to take place. An appropriate form of attestation of documents by Trust would be:

.8.2.3 "The Common Seal of the Oxford University Hospitals NHS Trust was hereunto

affixed in the presence of ........."

8.3 Register of Sealing The Chief Executive shall keep a register in which he/she, or another manager of

the Authority authorised by him/her, shall enter a record of the sealing of every document. An entry of every sealing and signing shall be made, and numbered consecutively in a book provided for that purpose, and shall be signed by the persons who shall have approved and authorized the document and those who attested the seal. A report that describes each seal / signing number, a description of each document involved, and the date of each sealing / signing shall be made to the Board at its next public meeting. The register will also include those agreements with third parties entered into by the Trust e.g. with commercial organizations.

8.4 Signature of documents Where any document will be a necessary step in legal proceedings on behalf of the

Trust, it shall, unless any enactment otherwise requires or authorises, be signed by the Chief Executive or any Executive Director.

In land transactions, the signing of certain supporting documents will be delegated

to Managers and set out clearly in the Scheme of Delegation but will not include the main or principal documents effecting the transfer (e.g. sale/purchase agreement, lease, contracts for construction works and main warranty agreements or any document which is required to be executed as a deed).

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9. MISCELLANEOUS (see overlap with SFI No. 21.3) 9.1 Joint Finance Arrangements The Board may confirm contracts to purchase from a voluntary organisation or a

local authority using its powers under Section 28A of the NHS Act 1977. The Board may confirm contracts to transfer money from the NHS to the voluntary sector or the health related functions of local authorities where such a transfer is to fund services to improve the health of the local population more effectively than equivalent expenditure on NHS services, using its powers under Section 28A of the NHS Act 1977, as amended by section 29 of the Health Act 1999.

See overlap with Standing Financial Instruction No. 21.3. 9.2 Working with others

Although the Trust is not currently party to any formal partnership arrangements (as set down in HSC 2000/010), it works in partnership and collaboratively with organizations and bodies that include:

- Oxford University, with whom a strategic Partnership Board has been established

- Oxford Brookes University - Oxfordshire Primary Care Trust and other commissioning Primary Care

Trusts. - The Directorate of Social and Health Care Oxfordshire County Council - Other NHS Trusts and NHS Foundation Trusts

The collaborations with the above bodies cover such areas as teaching, education and research; and participation in work that impacts on the whole of the healthcare and social care community e.g. in discharge planning, in emergency planning, and in the management of „winter pressures‟. For several of these areas, which tend to cover operational activities, formal committees have been established, and a Trust Executive Director has been designated as the lead. The Board will receive reports as appropriate and the Board sub committee may also receive updates.

- Provide a forum to support and direct strategic co-operation and alignment between the Trust and the University, in order to maximize opportunities for the development of clinical practice, teaching and research by both organizations acting in concert.

- Maintain an oversight of all research and development activity (including

the Oxford Biomedical Research Centre) sponsored by the partners, and oversee the work of the steering Committee of the Biomedical Research Centre. This will include approval of resource and financial allocations by the Centre

- Maintain an oversight of senior clinical and academic appointments to the Trust and the Medical Sciences Division of the University, to ensure congruence with the strategic plans of the partnership.

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SECTION C - SCHEME OF RESERVATION AND DELEGATION

REF THE BOARD DECISIONS RESERVED TO THE BOARD

NA THE BOARD General Enabling Provision The Board may determine any matter, for which it has delegated or statutory authority, it wishes in full session within its statutory powers.

NA THE BOARD Regulations and Control 1. Approve Standing Orders (SOs), a schedule of matters reserved to the Board and Standing Financial

Instructions for the regulation of its proceedings and business. 2. Suspend Standing Orders. 3. Vary or amend the Standing Orders. 4. Ratify any urgent decisions taken by the Chairman and Chief Executive in public session in

accordance with SO 5.2 5. Approve a scheme of delegation of powers from the Board to committees. 6. Require and receive the declaration of Board members‟ interests that may conflict with those of the

Trust and determining the extent to which that member may remain involved with the matter under consideration.

7. Require and receive the declaration of officers‟ interests that may conflict with those of the Trust. 8. Approve arrangements for dealing with complaints and receive an annual report on complaints. 9. Adopt the organisation structures, processes and procedures to facilitate the discharge of business

by the Trust and to agree modifications thereto. 10. Receive reports from committees including those that the Trust is required by the Secretary of State

or other regulation to establish and to take appropriate action on such reports. 11. Confirm the recommendations of the Trust‟s committees where the committees do not have

executive powers. 12. Establish terms of reference and reporting arrangements of all committees and sub-committees that

are established by the Board. 13. Approve arrangements relating to the discharge of the Trust‟s responsibilities as a bailer for patients‟

property. 14. Authorise use of the seal. 15. Ratify or otherwise instances of failure to comply with Standing Orders brought to the Chief

Executive‟s attention in accordance with SO 5.6.



16. Discipline members of the Board or employees who are in breach of statutory requirements or SOs.

NA THE BOARD Appointments/ Dismissal

1. Appoint the Vice Chairman of the Board. 2. The appointment and dismissal of Associates of the Trust Board 3. Appoint and dismiss committees (and individual members) that are directly accountable to the

Board. 4. Appoint, discipline and dismiss Executive Directors (subject to SO 2.2) 5. Confirm appointment of members of any committee of the Trust as representatives on outside

bodies. 6. Appoint, discipline and dismiss the Board Secretary (subject to SO 2.2 7. Approve proposals of the Remuneration and Appointments Committee regarding directors and

senior employees and those of the Chief Executive for staff not covered by the Remuneration and Appointments Committee.

NA THE BOARD Strategy, Plans and Budgets 1. Define the strategic aims and objectives of the Trust each year. 2. Approve proposals for ensuring quality and developing clinical governance in services provided by

the Trust, having regard to any guidance issued by the Secretary of State. 3. Approve the Trust‟s policies and procedures for the management of risk. 4. Approve the Trust‟s policies and procedures for the management of health and safety and receive an

annual report on health and safety. 5. Approve Outline and Final Business Cases for Capital Investment. 6. Approve the budgets and the Trust‟s financial plan. 7. Approve annually Trust‟s proposed organisational development proposals. 8. Ratify proposals for acquisition, disposal or change of use of land and/or buildings. 9. Approve PFI proposals. 10. Approve the opening of bank or investment accounts. 11. Approve proposals on individual contracts (other than NHS contracts) of a capital or revenue nature

amounting to, or likely to amount to over £1,000,000 over a 3 year period or the period of the contract if longer.

12. Approve proposals in individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Executive and Director of Finance and Procurement (for losses



and special payments) previously approved by the Board. 13. Approve individual compensation payments. 14. Approve proposals for action on litigation against or on behalf of the Trust. 15. Review use of NHSLA risk pooling schemes (LPST/CNST/RPST). 16. Receive annual reports on Child protection, comments and Complaints, and Control of Infection.

THE BOARD Policy Determination 1. Approve management policies including personnel policies incorporating the arrangements for the

appointment, removal and remuneration of staff.

Policies so adopted shall be listed and appended to this document by the Board Secretary

THE BOARD Audit 1. To note the appointment (and, where necessary, dismissal) of External Auditor, and advise the Audit

Commission on the appointment.

2. Receive of the annual management letter received from the external auditor and agreement of proposed action, taking account of the advice, where appropriate, of the Audit and Finance Committee.

3. Receive an annual report from the Internal Auditor and agree action on recommendations where appropriate of the Audit and Finance Committee.

4. To approve the appointment (and where necessary dismissal) of the internal auditors.

NA THE BOARD Annual Reports and Accounts

1. Receipt and approval of the Trust's Annual Report and Annual Accounts.

NA THE BOARD Monitoring

1. Receive of such reports as the Board sees fit from committees in respect of their exercise of powers delegated. 2. Continuous appraisal of the affairs of the Trust by means of the provision to the Board as the Board may require

from directors, committees, and officers of the Trust as set out in management policy statements. All monitoring returns required by the Department of Health shall be reported, at least in summary, to the Board.

3. Receive reports on all aspects of the Trust‟s performance, and particularly those covering performance against budget, financial plans, performance improvement plans, internal or national targets, and measures of activity



and quality.

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DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES

REF COMMITTEE DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES

SFI 11.1.1 AUDIT AND FINANCE

COMMITTEE

The Committee will:

(A) in respect of Audit

1.1 Internal Control and Risk Management

- ensure the provision and maintenance of an effective system of financial risk identification and associated controls, reporting and governance.

- maintain an oversight of the Trust‟s general risk management structures, processes and responsibilities, including the production and issue of any risk and control related disclosure statements.

- review the risk register at each meeting or as the Board determines.

- monitor and review the Board Assurance Framework, and ensure its presentation to the Trust Board at intervals that the Board determines

- receive and consider the Statement on Internal Control, making recommendations to the Board for approval, where appropriate.

- review the adequacy of the policies and procedures for all counter fraud work. - review the adequacy of the Trust‟s arrangements by which staff may, in confidence, raise

concerns about possible improprieties in matters of financial reporting and control, or related matters or other matters of concern.

- oversee the maintenance of the policy framework of the Trust, in particular the Policy for Policy & Procedural Documents.

1.2 Internal Audit

- oversee the effective operation of Internal Audit and ensure its co-ordination with External Audit.

- review the Internal Audit programme, consider the major findings of Internal Audit investigations and management‟s response, and monitor progress on implementation of recommendations.

1.3 External Audit

- assess the External Auditor‟s work and fees on an annual basis.

- discuss with the External Auditor, before the audit commences, the nature and scope of the audit, and ensure co-ordination, as appropriate, with other External Auditors in the local health



economy.

- review External Audit reports, including the Annual Audit Letter, together with the management response, and to monitor progress on the implementation of recommendations.

- develop and implement a policy on the External Auditor to supply non-audit services.

1.3 Annual Account Review

- review the Trust‟s annual statutory accounts, before they are presented to the Trust Board, to determine their objectivity, integrity and accuracy. This review will cover:

o The meaning and significance of the figures, notes and significant changes; o Accounting policies and practices followed and significant changes; o Explanation of estimates or provisions having material effect; o The schedule of losses and special payments; o Any reservations and disagreements between the External Auditors and management not

satisfactorily resolved.

1.5 Standing Orders, Standing Financial Instructions and Standards of Business Conduct

- review on behalf of the Trust Board the operation of, and proposed changes to the Standing Orders and Standing Financial Instructions, Codes of Conduct and Standards of Business Conduct; including maintenance of registers of interest.

- examine the circumstances of any significant departure from the requirements of any of the foregoing.

- review the Scheme of Delegation.

1.6 Other audit related issues - review performance indicators relevant to the Committee. - examine any other matter referred to the Committee by the Trust Board and to initiate

investigation as determined by the Committee. - annually review the accounting policies of the Trust and make appropriate recommendations to

the Trust Board.

11. (B) in respect of Finance 12.



2.1 Financial Policy , Management & Reporting

- consider the Trust‟s medium and long term financial strategy, in relation to both revenue and capital.

- consider the Trust‟s annual financial targets and performance against them.

- consider the Trust‟s financial performance, in terms of the relationship between underlying activity, income and expenditure, and the respective budgets.

- commission and receive the results of in-depth reviews of key financial issues affecting the Trust.

- annually review the financial policies of the Trust and make appropriate recommendations to the Trust Board.

2.2 Other financial related issues - monitor, and make recommendations on, as necessary, the adequacy and effectiveness of the

Trust‟s performance reporting.

- make arrangements as necessary to ensure that all members of the Trust Board maintain an appropriate level of knowledge and understanding of key financial issues affecting the Trust.

- examine any other matter referred to the Committee by the Trust Board.

- review performance indicators relevant to the financial remit of the Committee.

SFI 20.1.2 REMUNERATION AND

APPOINTMENTS

COMMITTEE

The Committee will:

have delegated authority to determine the policy and management of Executive Director remuneration,

including base pay, variable pay contingent on performance, contracts and terms of service, termination arrangements and pensions, ensuring they are fairly rewarded for their individual contribution to the organisation – having proper regard to the organisation‟s circumstances and performance, and to the provisions of any national agreements where appropriate.

(1.2 in determining remuneration for Executive Directors, the Committee shall review and agree: - overall market positioning of the remuneration package; - individual base salaries and increases; - relevant targets for performance related schemes. 1.3 ensures that the right performance management arrangements are in place for Executive

Directors and work with the Chief Executive to relate performance judgments to pay.



2 approve the contract of employment for each Executive Director, including termination

arrangements. 3 scrutinize and agree terms for the termination of a contract giving due regard to Treasury

guidance. 4 In determining remuneration policy and packages, the Committee shall have regard to the

Trust‟s overarching reward and benefit strategy for all staff, the arrangements in the wider NHS and any extant guidance from the Treasury.

5 undertake any other duties as directed by the Board.

1

BOARD IN COMMITTEE The Committee will:- 1 Consider specific aspects of strategy across the Trust‟s full range of activity, facilitating

involvement in the development of strategy at an early stage.

2 Review and discuss the wider experiences of patients and staff, examining both good & poor practice in the context of overall services provided by the Trust.

3 Provide a forum for discussion and informal exchange of Non-Executive Director experiences following visits and safety walkabouts in service areas.

4 Promote and facilitating team-working amongst the Board.

5 Develop and maintain the Board‟s education and development programme, ensuring that Board members receive regular updates on both internal and external developments.

6 Undertake any other duties as delegated by the Trust Board.



QUALITY

COMMITTEE

The Committee will:- 1 Oversee and maintain an effective system for safety within the Trust, with particular focus on;

patient safety, staff safety and wider heath & safety requirements.

2 Oversee and maintain an effective system for delivering a high quality experience for all its patients and users, with particular focus on involvement and engagement for the purposes of learning and making improvement.

3 Oversee and maintain an effective system for monitoring clinical outcomes and clinical effectiveness, with particular focus on ensuring patients receive the best possible outcomes of care across the full range of Trust activities.

4 Ensure the Trust maintains compliance with the Care Quality Commission registration via assurance of the systems of control, with particular emphasis on the 16 standards of safety & quality.

5 Be responsible for the oversight and assurance of statutory and mandatory requirements, relating to quality of care.

6 Be responsible for the oversight and assurance of external assessment systems (such as NHSLA Risk Management Standards), professional bodies‟ and regulatory bodies‟ requirements.

7 Monitor and review the system for Human Resources Governance, ensuring that the Board is assured of continued compliance through regular reporting.

8 Monitor and review the system for Information Governance, ensuring that the Board is assured of continued compliance through regular reporting.

9 Monitor and review the system for Research & Development Governance, ensuring that the Board is assured of continued compliance through regular reporting.

10 Undertake any other duties as delegated by the Trust Board.

TRUST MANAGEMENT The Committee will:-



EXECUTIVE (TME) 1 Oversee the development of the Trust‟s service strategy by developing proposals for the Trust‟s strategic direction, as advised by the Strategic Planning Committee (SPC). The SPC will make recommendations for consideration by the Trust Management Executive, to enable TME to make further recommendations to the Trust Board.

2 Oversee the implementation of strategic directions and work plan within the overall strategy set by the Trust Board,

3 Develop and agree objectives for submission to the Board to deliver the agreed strategy and then agree detailed capital and revenue business plans to deliver the objectives,

4 Closely monitor standards of care, quality and safety by ensuring appropriate actions are taken, as advised by the Clinical Governance Committee,

5 Identify and mitigate risk by monitoring the risk register and assurance framework, agreeing resourced action plans and ensuring their delivery,

6 Develop, agree and monitor implementation of plans to improve the efficiency, effectiveness and quality of the Trust‟s services.

7 Monitor the delivery of the Trust‟s service activity and financial objectives and agree actions, allocate responsibilities, and ensure delivery where necessary to deliver the Trust‟s objectives or other obligations, as advised by the Performance Committee.

8 Monitor and ensure the delivery of all specific actions agreed by the Board, by TME and by committees of both.

9 Monitor the delivery of the Trust‟s workforce strategy and plans, as advised by the Workforce Committee,

10 Monitor the delivery of the Trust‟s education & training strategy and plans, as advised by the Education & Training Committee,

11 Monitor the delivery of the Trust‟s R&D strategy and plans, as advised by the Research & Development Committee,

12 Monitor the delivery of the Trust‟s health informatics and technology strategy and plans, as advised by the Education & Training Committee,

13 Agree all policies – other than those retained by the Trust Board - to ensure the delivery of external and internal governance and best practice requirements and compliance.

14 Approve major bids for submission to the Oxford University Hospitals Section 11 trustees or any other charity willing to support, the Trust‟s services or staff.

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SCHEME OF DELEGATION DERIVED FROM THE ACCOUNTABLE OFFICER MEMORANDUM

REF DELEGATED TO DUTIES DELEGATED

7 CHIEF EXECUTIVE

(CE) Accountable through NHS Accounting Officer to Parliament for stewardship of Trust resources

9 CE AND DIRECTOR OF

FINANCE AND

PROCUREMENT (DOF)

Ensure the accounts of the Trust are prepared under principles and in a format directed by the SofS. Accounts must disclose a true and fair view of the Trust‟s income and expenditure and its state of affairs.

Sign the accounts on behalf of the Board.

10 CHIEF EXECUTIVE Sign a statement in the accounts outlining responsibilities as the Accountable Officer.

Sign a statement in the accounts outlining responsibilities in respect of Internal Control.

12 & 13 CHIEF EXECUTIVE Ensure effective management systems that safeguard public funds and assist the Trust Chairman to implement requirements of corporate governance including ensuring managers:

“have a clear view of their objectives and the means to assess achievements in relation to those objectives

be assigned well defined responsibilities for making best use of resources

have the information, training and access to the expert advice they need to exercise their responsibilities effectively.”

12 CHAIRMAN Implement requirements of corporate governance.

13 CHIEF EXECUTIVE Achieve value for money from the resources available to the Trust and avoid waste and extravagance in the organisation's activities.

Follow through the implementation of any recommendations affecting good practice as set out on reports from such bodies as the Audit Commission and the National Audit Office (NAO).

15 DOF Operational responsibility for effective and sound financial management and information.

15 CHIEF EXECUTIVE Primary duty to see that DoF discharges this function.


REF DELEGATED TO DUTIES DELEGATED

16 CHIEF EXECUTIVE Ensuring that expenditure by the Trust complies with Parliamentary requirements.

18 CE and DoF Chief Executive, supported by Director of Finance and Procurement, to ensure appropriate advice is given to the Board on all matters of probity, regularity, prudent and economical administration, efficiency and effectiveness.

19 CHIEF EXECUTIVE If CE considers the Board or Chairman is doing something that might infringe probity or regularity, he/she should set this out in writing to the Chairman and the Board. If the matter is unresolved, he/she should ask the Audit and Finance Committee to inquire and if necessary the SHA and Department of Health.

21 CHIEF EXECUTIVE If the Board is contemplating a course of action that raises an issue not of formal propriety or regularity but affects the CE‟s responsibility for value for money, the CE should draw the relevant factors to the attention of the Board. If the outcome is that you are overruled it is normally sufficient to ensure that your advice and the overruling of it are clearly apparent from the papers. Exceptionally, the CE should inform the Strategic Health Authority and the DH. In such cases, and in those described in paragraph 24, the CE should as a member of the Board vote against the course of action rather than merely abstain from voting.

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SCHEME OF DELEGATION DERIVED FROM THE CODES OF CONDUCT AND ACCOUNTABILITY

REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

1.3.1.7 BOARD Approve procedure for declaration of hospitality and sponsorship.

1.3.1.8 BOARD Ensure proper and widely publicised procedures for voicing complaints, concerns about misadministration, breaches of Code of Conduct, and other ethical concerns.

1.31.9 & 1.3.2.2

ALL BOARD MEMBERS Subscribe to Code of Conduct.

1.3.2.4 BOARD Board members share corporate responsibility for all decisions of the Board.

1.3.2.4 CHAIR AND NON

EXECUTIVE/OFFICER

MEMBERS

Chair and non-officer members are responsible for monitoring the executive management of the organisation and are responsible to the SofS for the discharge of those responsibilities.

1.3.2.4 BOARD The Board has six key functions for which it is held accountable by the Department of Health on behalf of the Secretary of State: 1. to ensure effective financial stewardship through value for money, financial control and financial planning and strategy; 2. to ensure that high standards of corporate governance and personal behaviour are maintained in the conduct of the business of the whole organisation; 2. to appoint, appraise and remunerate senior executives; 3. to ratify the strategic direction of the organisation within the overall policies and priorities of the

Government and the NHS, define its annual and longer term objectives and agree plans to achieve them;

4. to oversee the delivery of planned results by monitoring performance against objectives and ensuring corrective action is taken when necessary;

5. to ensure effective dialogue between the organisation and the local community on its plans and performance and that these are responsive to the community's needs.

1.3.24 BOARD It is the Board‟s duty to:



1. act within statutory financial and other constraints; 2. be clear what decisions and information are appropriate to the Board and draw up Standing Orders,

a schedule of decisions reserved to the Board and Standing Financial Instructions to reflect these, 3. ensure that management arrangements are in place to enable responsibility to be clearly delegated

to senior executives for the main programmes of action and for performance against programmes to be monitored and senior executives held to account;

4. establish performance and quality measures that maintain the effective use of resources and provide value for money;

5. specify its requirements in organising and presenting financial and other information succinctly and efficiently to ensure the Board can fully undertake its responsibilities;

6. establish Audit and Remuneration Committees on the basis of formally agreed terms of reference that set out the membership of the sub-committee, the limit to their powers, and the arrangements for reporting back to the main Board.

1.3.2.5 CHAIRMAN It is the Chairman's role to:

1. provide leadership to the Board; 2. enable all Board members to make a full contribution to the Board's affairs and ensure that the

Board acts as a team; 3. ensure that key and appropriate issues are discussed by the Board in a timely manner, 4. ensure the Board has adequate support and is provided efficiently with all the necessary data on

which to base informed decisions; 5. lead Non-Executive Board members through a formally-appointed Remuneration Committee of

the main Board on the appointment, appraisal and remuneration of the Chief Executive and (with the latter) other Executive Board members;

6. appoint Non-Executive Board members to an Audit and Finance Committee of the main Board; 7. advise the Secretary of State on the performance of Non-Executive Board members.

1.3.2.5 CHIEF EXECUTIVE The Chief Executive is accountable to the Chairman and Non-Executive members of the Board for ensuring that its decisions are implemented, that the organisation works effectively, in accordance with Government policy and public service values and for the maintenance of proper financial stewardship. The Chief Executive should be allowed full scope, within clearly defined delegated powers, for action in fulfilling the decisions of the Board. The other duties of the Chief Executive as Accountable Officer are laid out in the Accountable Officer



Memorandum.

1.3.2.6 NON EXECUTIVE

DIRECTORS

Non-Executive Directors are appointed by Appointments Commission to bring independent judgement to bear on issues of strategy, performance, key appointments and accountability through the Department of Health to Ministers and to the local community.

1.3.2.8 CHAIR AND

DIRECTORS

Declaration of conflict of interests.

1.3.2.9 BOARD NHS Boards must comply with legislation and guidance issued by the Department of Health on behalf of the Secretary of State, respect agreements entered into by themselves or in on their behalf and establish terms and conditions of service that are fair to the staff and represent good value for taxpayers' money.

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SCHEME OF DELEGATION FROM STANDING ORDERS

SO REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

1.1 CHAIRMAN Final authority in interpretation of Standing Orders (SOs).

2.4 BOARD Appointment of Vice Chairman

3.1 CHAIRMAN Call meetings.

3.9 CHAIRMAN Chair all Board meetings and associated responsibilities.

3.10 CHAIRMAN Give final ruling in questions of order, relevancy and regularity of meetings.

3.12 CHAIRMAN Having a second or casting vote

3.13 BOARD Suspension of Standing Orders

3.13 AUDIT AND FINANCE

COMMITTEE Audit and Finance Committee to review every decision to suspend Standing Orders (power to suspend Standing Orders is reserved to the Board) and record each in an annual report.

3.14 BOARD Variation or amendment of Standing Orders

4.1 BOARD Formal delegation of powers to sub committees or joint committees and approval of their constitution and terms of reference. (Constitution and terms of reference of sub committees may be approved by the Chief Executive.)

5.2 CHAIRMAN & CHIEF

EXECUTIVE The powers which the Board has retained to itself within these Standing Orders may in emergency be exercised by the Chair and Chief Executive after having consulted at least two Non-Executive members.

5.4 CHIEF EXECUTIVE The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposals that shall be considered and approved by the Board, subject to any amendment agreed during the discussion.

5.6 ALL Disclosure of non-compliance with Standing Orders to the Chief Executive as soon as possible.

7.1 THE BOARD Declare relevant and material interests.

7.2 CHIEF EXECUTIVE Maintain Register(s) of Interests.


SO REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

7.4 ALL STAFF Comply with national guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff”.

7.4 ALL Disclose relationship between self and candidate for staff appointment. (CE to report the disclosure to the Board.)

8.1/8.3 CHIEF EXECUTIVE Keep seal in safe place and maintain a register of sealing.

8.4 CHIEF

EXECUTIVE/EXECUTIV

E DIRECTOR

Approve and sign all documents which will be necessary in legal proceedings.

* Nominated officers and the areas for which they are responsible should be incorporated into the Trust‟s Scheme of Delegation document.

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SCHEME OF DELEGATION FROM STANDING FINANCIAL INSTRUCTIONS

SFI REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

10.1.3 DIRECTOR OF FINANCE AND

PROCUREMENT Approval of all financial procedures.


PROCUREMENT Advice on interpretation or application of SFIs.

10.1.6 ALL MEMBERS OF THE

BOARD AND EMPLOYEES Have a duty to disclose any non-compliance with these Standing Financial Instructions to the Director of Finance and Procurement as soon as possible.

10.2.4 CHIEF EXECUTIVE

Responsible as the Accountable Officer to ensure financial targets and obligations are met and have overall responsibility for the system of Internal Control.

10.2.4 CHIEF EXECUTIVE &

DIRECTOR OF FINANCE AND

PROCUREMENT

Accountable for financial control but will, as far as possible, delegate their detailed responsibilities.

10.2.5 CHIEF EXECUTIVE To ensure all Board members, officers and employees, present and future, are notified of and understand Standing Financial Instructions.


PROCUREMENT Responsible for: a) Implementing the Trust's financial policies and coordinating corrective action;

b) Maintaining an effective system of financial control including ensuring detailed financial procedures and systems are prepared and documented;

c) Ensuring that sufficient records are maintained to explain Trust‟s transactions and financial position;

d) Providing financial advice to members of Board and staff;

e) Maintaining such accounts, certificates etc as are required for the Trust to carry out its statutory duties.


BOARD AND EMPLOYEES Responsible for security of the Trust's property, avoiding loss, exercising economy and efficiency in using resources and conforming to Standing Orders, Financial Instructions and financial procedures.

10.2.8 CHIEF EXECUTIVE Ensure that any contractor or employees of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income are made aware of these instructions and their



requirement to comply.

11.1.1 AUDIT AND FINANCE

COMMITTEE Provide independent and objective view on internal control and probity.

11.1.2 CHAIR Raise the matter at the Board meeting where Audit and Finance Committee considers there is evidence of ultra vires transactions or improper acts.

11.1.3 & 11.2.1


PROCUREMENT

Ensure an adequate internal audit service, for which he/she is accountable, is provided (and involve the Audit and Finance Committee in the selection process when/if an internal audit service provider is changed.)


PROCUREMENT Decide at what stage to involve police in cases of misappropriation and other irregularities not involving fraud or corruption.

11.3 HEAD OF INTERNAL AUDIT Review, appraise and report in accordance with NHS Internal Audit Manual and best practice.

11.4 AUDIT AND FINANCE

COMMITTEE Ensure cost-effective External Audit.

11.5 CHIEF EXECUTIVE &


PROCUREMENT

Monitor and ensure compliance with SofS Directions on fraud and corruption including the appointment of the Local Counter Fraud Specialist.

11.6 CHIEF EXECUTIVE Monitor and ensure compliance with Directions issued by the Secretary of State for Health on NHS security management including appointment of the Local Security Management Specialist.

13.1.1 CHIEF EXECUTIVE Compile and submit to the Board an Integrated Business Plan which takes into account financial targets and forecast limits of available resources. The Integrated Business Plan will contain:

a statement of the significant assumptions on which the plan is based;

details of major changes in workload, delivery of services or resources required to achieve the plan.

13.1.2 & 13.1.3


PROCUREMENT Submit budgets to the Board for approval.

Monitor performance against budget; submit to the Board financial estimates and forecasts.


PROCUREMENT Ensure adequate training is delivered on an on going basis to budget Managers.



13.3.1 CHIEF EXECUTIVE Delegate budget to budget Managers.

13.3.2 CHIEF EXECUTIVE &

BUDGET MANAGERS Must not exceed the budgetary total or virement limits set by the Board.


PROCUREMENT Devise and maintain systems of budgetary control.

13.4.2 BUDGET MANAGERS Ensure that

a) no overspend or reduction of income that cannot be met from virement is incurred without prior consent of Board; b) approved budget is not used for any other than specified purpose subject to rules of virement; c) no permanent employees are appointed without the approval of the CE other than those provided for within available resources and manpower establishment.

13.4.3 CHIEF EXECUTIVE Identify and implement cost improvements and income generation activities in line with the Integrated Business Plan

13.6.1 CHIEF EXECUTIVE Submit monitoring returns

14.1 DIRECTOR OF FINANCE AND

PROCUREMENT Preparation of annual accounts and reports.


PROCUREMENT Managing banking arrangements, including provision of banking services, operation of accounts, preparation of instructions and list of cheque signatories.

(Board approves arrangements.)

16. DIRECTOR OF FINANCE AND

PROCUREMENT Income systems, including system design, prompt banking, review and approval of fees and charges, debt recovery arrangements, design and control of receipts, provision of adequate facilities and systems for employees whose duties include collecting or holding cash.

16.2.3 ALL EMPLOYEES Duty to inform DoF of money due from transactions which they initiate/deal with.

17. CHIEF EXECUTIVE Tendering and contract procedure.

17.5.3 CHIEF EXECUTIVE Waive formal tendering procedures.



17.5.3 CHIEF EXECUTIVE Report waivers of tendering procedures to the Board.


PROCUREMENT

17.6.2 CHIEF EXECUTIVE Responsible for the receipt, endorsement and safe custody of tenders received.

17.6.3 CHIEF EXECUTIVE Shall maintain a register to show each set of competitive tender invitations despatched.

17.6.4 CHIEF EXECUTIVE AND


PROCUREMENT

Where one tender is received will assess for value for money and fair price.

17.6.6 CHIEF EXECUTIVE No tender shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these Instructions except with the authorisation of the Chief Executive.

17.6.8 CHIEF EXECUTIVE Will appoint a manager to maintain a list of approved firms.

17.6.9 CHIEF EXECUTIVE Shall ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

17.7.2 CHIEF EXECUTIVE The Chief Executive or his nominated officer should evaluate the quotation and select the quote which gives the best value for money.

17.7.4 CHIEF EXECUTIVE or DIRECTOR OF FINANCE AND

PROCUREMENT

No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these Instructions except with the authorisation of the Chief Executive.

17.10 CHIEF EXECUTIVE The Chief Executive shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector.

17.10 BOARD All PFI proposals must be agreed by the Board.

17.11 CHIEF EXECUTIVE The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.



17.12 CHIEF EXECUTIVE The Chief Executive shall nominate officers with delegated authority to enter into contracts of employment, regarding staff, agency staff or temporary staff service contracts.

17.15 CHIEF EXECUTIVE The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided on an in-house basis.

17.15.5 CHIEF EXECUTIVE The Chief Executive shall nominate an officer to oversee and manage the contract on behalf of the Trust.

18.1.1 CHIEF EXECUTIVE Must ensure the Trust enters into suitable Service Level Agreements (SLAs) with service commissioners for the provision of NHS services

18.3 CHIEF EXECUTIVE As the Accountable Officer, ensure that regular reports are provided to the Board detailing actual and forecast income from the SLA

20.1.1 BOARD Establish a Remuneration & Appointments Committee

20.1.2 Remuneration & Appointments Committee

Advise the Board on and make recommendations on the remuneration and terms of service of the CE, other officer members and senior employees to ensure they are fairly rewarded having proper regard to the Trust’s circumstances and any national agreements; Monitor and evaluate the performance of individual senior employees; Advise on and oversee appropriate contractual arrangements for such staff, including proper calculation and scrutiny of termination payments.

20.1.3 Remuneration & Appointments Committee

Report in writing to the Board its advice and its bases about remuneration and terms of service of directors and senior employees.

20.1.4 BOARD Approve proposals presented by the Chief Executive for setting of remuneration and conditions of service for those employees and officers not covered by the Remuneration & Appointments Committee.

20.2.2 CHIEF EXECUTIVE Approval of variation to funded establishment of any department.

20.3 CHIEF EXECUTIVE Staff, including agency staff, appointments and re-grading.

20.4.1 and 20.4.2


PROCUREMENT Payroll:

a) specifying timetables for submission of properly authorised time records and other notifications; b) final determination of pay and allowances; c) making payments on agreed dates; d) agreeing method of payment;



e) issuing instructions (as listed in SFI 10.4.2).

20.4.3 DIRECTOR OF

WORKFORCE

Submit time records in line with timetable.

Complete time records and other notifications in required form.

Submitting termination forms in prescribed form and on time.


PROCUREMENT

Ensure that the chosen method for payroll processing is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

20.5 DIRECTOR OF

WORKFORCE

Ensure that all employees are issued with a Contract of Employment in a form approved by the Board and which complies with employment legislation; and Deal with variations to, or termination of, contracts of employment.

21.1 CHIEF EXECUTIVE Determine, and set out, level of delegation of non-pay expenditure to budget managers, including a list of managers authorised to place requisitions, the maximum level of each requisition and the system for authorisation above that level.

21.1.3 CHIEF EXECUTIVE Set out procedures on the seeking of professional advice regarding the supply of goods and services.

21.2.1 Budget Manager

In choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust's adviser on supply shall be sought.


PROCUREMENT Shall be responsible for the prompt payment of accounts and claims.


PROCUREMENT

a) Advise the Board regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in standing orders and regularly reviewed;

b) Prepare procedural instructions [where not already provided in the Scheme of Delegation or procedure notes for budget Managers] on the obtaining of goods, works and services incorporating



the thresholds; c) Be responsible for the prompt payment of all properly authorised accounts and claims; d) Be responsible for designing and maintaining a system of verification, recording and payment of all

amounts payable; e) A timetable and system for submission to the Director of Finance and Procurement of accounts for

payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment;

f) Instructions to employees regarding the handling and payment of accounts within the Finance Department;

g) Be responsible for ensuring that payment for goods and services is only made once the goods and services are received

21.2.4 APPROPRIATE EXECUTIVE

DIRECTOR

Make a written case to support the need for a prepayment.


PROCUREMENT Approve proposed prepayment arrangements.

21.2.4 BUDGET MANAGER Ensure that all items due under a prepayment contract are received (and immediately inform DoF if problems are encountered).

21.2.5 CHIEF EXECUTIVE Authorise who may use and be issued with official orders.


BOARD AND EMPLOYEES Ensure that they comply fully with the guidance and limits specified by the Director of Finance and Procurement.

21.2.7 CHIEF EXECUTIVE


PROCUREMENT

Ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within CONCODE and ESTATECODE. The technical audit of these contracts shall be the responsibility of the relevant Director.


PROCUREMENT

Lay down procedures for payments to local authorities and voluntary organisations made under the powers of section 28A of the NHS Act.

22.1.1 DIRECTOR OF FINANCE AND The DoF will advise the Board on the Trust‟s ability to pay dividend on PBC and report, periodically, concerning the PDC debt and all loans and overdrafts.



PROCUREMENT

22.1.2 BOARD Approve a list of employees authorised to make short term borrowings on behalf of the Trust. (This must include the CE and DoF.)


PROCUREMENT

Prepare detailed procedural instructions concerning applications for loans and overdrafts.

22.1.4 CHIEF EXECUTIVE OR


PROCUREMENT

Be on an authorising panel comprising one other member for short term borrowing approval.


PROCUREMENT

Will advise the Board on investments and report, periodically, on performance of same.


PROCUREMENT

Prepare detailed procedural instructions on the operation of investments held.

23 DIRECTOR OF FINANCE AND

PROCUREMENT Ensure that Board members are aware of the Financial Framework and ensure compliance

24.1.1 & 2 CHIEF EXECUTIVE Capital investment programme:

a) ensure that there is adequate appraisal and approval process for determining capital expenditure priorities and the effect that each has on plans

b) responsible for the management of capital schemes and for ensuring that they are delivered on time and within cost;

c) ensure that capital investment is not undertaken without availability of resources to finance all revenue consequences;

d) ensure that a business case is produced for each proposal.


PROCUREMENT Certify professionally the costs and revenue consequences detailed in the business case for capital investment.

24.1.3 CHIEF EXECUTIVE Issue procedures for management of contracts involving stage payments.


PROCUREMENT

Assess the requirement for the operation of the construction industry taxation deduction scheme.




PROCUREMENT

Issue procedures for the regular reporting of expenditure and commitment against authorised capital expenditure.

24.1.6 CHIEF EXECUTIVE Issue manager responsible for any capital scheme with authority to commit expenditure, authority to proceed to tender and approval to accept a successful tender. Issue a scheme of delegation for capital investment management.


PROCUREMENT

Issue procedures governing financial management, including variation to contract, of capital investment projects and valuation for accounting purposes.


PROCUREMENT

Demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector.

24.2.1 BOARD Proposal to use PFI must be specifically agreed by the Board.

24.3.1 CHIEF EXECUTIVE Maintenance of asset registers (on advice from DoF).


PROCUREMENT Approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

24.4.1 CHIEF EXECUTIVE Overall responsibility for fixed assets.


PROCUREMENT Approval of fixed asset control procedures.

24.4.4 BOARD, EXECUTIVE

MEMBERS AND ALL SENIOR

STAFF

Responsibility for security of Trust assets including notifying discrepancies to DoF, and reporting losses in accordance with Trust procedure.

25.2 CHIEF EXECUTIVE Delegate overall responsibility for control of stores (subject to DoF responsibility for systems of control). Further delegation for day-to-day responsibility subject to such delegation being recorded. (Good practice to append to the scheme of delegation document.)


PROCUREMENT Responsible for systems of control over stores and receipt of goods.



25.2 DESIGNATED

PHARMACEUTICAL OFFICER Responsible for controls of pharmaceutical stocks

25.2 DIRECTOR OF

DEVELOPMENT & THE

ESTATE.

Responsible for control of stocks of fuel oil and coal.

25.2 DIRECTOR OF

DEVELOPMENT & THE

ESTATE.

Security arrangements and custody of keys


PROCUREMENT Set out procedures and systems to regulate the stores.


PROCUREMENT Agree stocktaking arrangements.


PROCUREMENT Approve alternative arrangements where a complete system of stores control is not justified.


PROCUREMENT Approve system for review of slow moving and obsolete items and for condemnation, disposal and replacement of all unserviceable items.

25.2 Head of Procurement Operate system for slow moving and obsolete stock, and report to DoF evidence of significant overstocking.

25.3.1 CHIEF EXECUTIVE Identify persons authorised to requisition and accept goods from NHS Supplies stores.


PROCUREMENT Prepare detailed procedures for disposal of assets including condemnations and ensure that these are notified to managers.


PROCUREMENT

Prepare procedures for recording and accounting for losses, special payments and informing police in cases of suspected arson or theft.

26.2.2 ALL STAFF Discovery or suspicion of loss of any kind must be reported immediately to either head of department or nominated officer. The head of department / nominated officer should then inform the CE and DoF.




PROCUREMENT Where a criminal offence is suspected, DoF must inform the police if theft or arson is involved. In cases of fraud and corruption DoF must inform the relevant LCFS and NHS Protect in line with SoS directions.


PROCUREMENT Notify NHS Protect and External Audit of all frauds.


PROCUREMENT Notify Board and External Auditor of losses caused theft, arson, neglect of duty or gross carelessness (unless trivial).

26.2.4 BOARD Approve write off of losses (within limits delegated by DH).


PROCUREMENT Consider whether any insurance claim can be made.


PROCUREMENT Maintain losses and special payments register.


PROCUREMENT Responsible for accuracy and security of computerised financial data.


PROCUREMENT Satisfy himself that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation assurance of adequacy must be obtained from them prior to implementation.

27.1.3 DIRECTOR OF PLANNING

AND INFORMATION. Shall publish and maintain a Freedom of Information Scheme.

27.2.1 RELEVANT OFFICERS Send proposals for general computer systems to DoF


PROCUREMENT Ensure that contracts with other bodies for the provision of computer services for financial applications clearly define responsibility of all parties for security, privacy, accuracy, completeness and timeliness of data during processing, transmission and storage, and allow for audit review. Seek periodic assurances from the provider that adequate controls are in operation.

27.4 DIRECTOR OF PLANNING

AND INFORMATION. Ensure that risks to the Trust from use of IT are identified and considered and that disaster recovery plans are in place.

27.5 DIRECTOR OF PLANNING

AND INFORMATION. Where computer systems have an impact on corporate financial systems satisfy himself that: a) systems acquisition, development and maintenance are in line with corporate policies;



b) data assembled for processing by financial systems is adequate, accurate, complete and timely, and that a management rail exists;

c) DoF and staff have access to such data; Such computer audit reviews are being carried out as are considered necessary.

28.2 CHIEF EXECUTIVE Responsible for ensuring patients and guardians are informed about patients' money and property procedures on admission.


PROCUREMENT Provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of.

28.6 DEPARTMENTAL MANAGERS Inform staff of their responsibilities and duties for the administration of the property of patients.


PROCUREMENT Shall ensure that each trust fund which the Special Trustees are responsible for managing is managed appropriately. This includes:-

Administration of all existing charitable funds

To identify any new charity that may be created (of which the Special Trustees are trustee) and to deal with any legal steps that may be required to formalise the trusts of any such charity

Provide guidelines with respect to donations, legacies and bequests, fundraising and trading income

Responsibility for the management of investment of funds held on trust

Ensure appropriate banking services are available to the Special Trustees

Prepare reports to the Special Trustees including the annual accounts.

30 DIRECTOR OF FINANCE AND

PROCUREMENT Ensure all staff are made aware of the Trust policy on the acceptance of gifts and other benefits in kind by staff

32 CHIEF EXECUTIVE Retention of document procedures in accordance with HSC 1999/053.

33.1 CHIEF EXECUTIVE Risk management programme.

33.1 BOARD Approve and monitor risk management programme.

33.2 BOARD Decide whether the Trust will use the risk pooling schemes administered by the NHS Litigation Authority



or self-insure for some or all of the risks (where discretion is allowed). Decisions to self-insure should be reviewed annually.


PROCUREMENT Where the Board decides to use the risk pooling schemes administered by the NHS Litigation Authority the Director of Finance and Procurement shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Director of Finance and Procurement shall ensure that documented procedures cover these arrangements. Where the Board decides not to use the risk pooling schemes administered by the NHS Litigation Authority for any one or other of the risks covered by the schemes, the Director of Finance and Procurement shall ensure that the Board is informed of the nature and extent of the risks that are self insured as a result of this decision. The Director of Finance and Procurement will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.


PROCUREMENT Ensure documented procedures cover management of claims and payments below the deductible.

* Nominated officers and the areas for which they are responsible should be incorporated into the Trust‟s Scheme of Delegation document.

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SECTION D - STANDING FINANCIAL INSTRUCTIONS

10. INTRODUCTION

10.1 General 10.1.1 These Standing Financial Instructions (SFIs) are issued in accordance with the

Trust (Functions) Directions 2000 issued by the Secretary of State which require that each Trust shall agree Standing Financial Instructions for the regulation of the conduct of its members and officers in relation to all financial matters with which they are concerned. They shall have effect as if incorporated in the Standing Orders (SOs).

10.1.2 These Standing Financial Instructions detail the financial responsibilities, policies

and procedures adopted by the Trust. They are designed to ensure that the Trust's financial transactions are carried out in accordance with the law and with Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Decisions Reserved to the Board and the Scheme of Delegation adopted by the Trust.

10.1.3 These Standing Financial Instructions identify the financial responsibilities which

apply to everyone working for the Trust and its constituent organisations including Trading Units. They do not provide detailed procedural advice and should be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures must be approved by the Director of Finance and Procurement.

10.1.4 Should any difficulties arise regarding the interpretation or application of any of the

Standing Financial Instructions then the advice of the Director of Finance and

Procurement must be sought before acting. The user of these Standing

Financial Instructions should also be familiar with and comply with the provisions of the Trust‟s Standing Orders.

10.1.5 The failure to comply with Standing Financial Instructions and Standing Orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.

10.1.6 Overriding Standing Financial Instructions – If for any reason these Standing

Financial Instructions are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Audit and Finance Committee for referring action or ratification. All members of the Board and staff have a duty to disclose any non-compliance with these Standing Financial Instructions to the Director of Finance and Procurement as soon as possible.

10.1.7 Outsourced Services – Where any operation is carried out on the Trust‟s behalf by

NHS Shared Business Services or any other Board approved outsourced service provider, detailed procedures will be the responsibility of such a provider.

10.2 Responsibilities and delegation 10.2.1 The Trust Board The Board exercises financial supervision and control by: (a) formulating the financial strategy;


(b) requiring the submission and approval of budgets within approved allocations/overall income;

(c) defining and approving essential features in respect of important procedures

and financial systems (including the need to obtain value for money);

(d) defining specific responsibilities placed on members of the Board and employees as indicated in the Scheme of Delegation document.

10.2.2 The Board has resolved that certain powers and decisions may only be exercised

by the Board in formal session. These are set out in the („Reservation of Matters Reserved to the Board‟) section c above. All other powers have been delegated to such other committees as the Trust has established, as set out in the Scheme of Delegation.

10.2.4 The Chief Executive and Director of Finance and Procurement The Chief Executive and Director of Finance and Procurement will, as far as

possible, delegate their detailed responsibilities, but they remain accountable for financial control.

Within the Standing Financial Instructions, it is acknowledged that the Chief

Executive is ultimately accountable to the Board, and as Accountable Officer, to the Secretary of State, for ensuring that the Board meets its obligation to perform its functions within the available financial resources. The Chief Executive has overall executive responsibility for the Trust‟s activities; is responsible to the Chairman and the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust‟s system of internal control.

10.2.5 It is a duty of the Chief Executive to ensure that Members of the Board and,

employees and all new appointees are notified of, and put in a position to understand their responsibilities within these Instructions.

10.2.6 The Director of Finance and Procurement The Director of Finance and Procurement is responsible for:

(a) implementing the Trust‟s financial policies and for coordinating any corrective action necessary to further these policies;

(b) maintaining an effective system of internal financial control including ensuring

that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions;

(c) ensuring that sufficient records are maintained to show and explain the

Trust‟s transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time;

and, without prejudice to any other functions of the Trust, and employees of the

Trust, the duties of the Director of Finance and Procurement include:

(d) the provision of financial advice to other members of the Board and employees;

(e) the design, implementation and supervision of systems of internal financial

control;


(f) the preparation and maintenance of such accounts, certificates, estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

10.2.7 Board Members and Employees All members of the Board and employees, severally and collectively, are

responsible for: (a) the security of the property of the Trust;

(b) avoiding loss; (c) exercising economy and efficiency in the use of resources; (d) conforming to the requirements of Standing Orders, Standing Financial

Instructions, Financial Procedures and the Scheme of Delegation. 10.2.8 Contractors and their employees Any contractor or employee of a contractor who is empowered by the Trust to

commit the Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

10.2.9 For all members of the Board and any employees who carry out a financial function,

the form in which financial records are kept and the manner in which members of the Board and employees discharge their duties must be to the satisfaction of the Director of Finance and Procurement.

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11. AUDIT 11.1 Audit and Finance Committee 11.1.1 In accordance with Standing Orders, the Board shall formally establish an Audit and

Finance Committee, with clearly defined terms of reference and following guidance from the NHS Audit Committee Handbook (2011) and the Audit Code for NHS Foundation Trusts published by the Independent Regulator, which will provide an independent and objective view of internal control by:

(a) overseeing Internal and External Audit services;

(b) reviewing financial and information systems and monitoring the integrity of

the financial statements and reviewing significant financial reporting judgments;

(c) work with the Quality Committee to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation‟s activities (both clinical and non-clinical), that supports the achievement of the organisation‟s objectives;

(d) monitoring compliance with Standing Orders and Standing Financial

Instructions; (e) reviewing schedules of losses and compensations and making

recommendations to the Board;

(f) reviewing schedules of debtors/creditors balances over 6 months and £5,000

old and seeking explanations/action plans; (g) Reviewing the arrangements in place to support the Assurance Framework

process prepared on behalf of the Board and advising the Board accordingly. 11.1.2 Where the Audit and Finance Committee considers there is evidence of ultra vires

transactions, evidence of improper acts, or if there are other important matters that the Committee wishes to raise, the Chairman of the Audit and Finance Committee should inform the Chief Executive and Director of Finance & Procurement and raise the matter at a full meeting of the Board. Exceptionally, the matter may need to be referred to the Department of Health.

11.1.3 It is the responsibility of the Director of Finance and Procurement to ensure an

adequate Internal Audit service is provided and the Audit and Finance Committee shall be involved in the selection process when/if an Internal Audit service provider is changed.

11.2 Director of Finance and Procurement 11.2.1 The Director of Finance and Procurement is responsible for:

(a) ensuring there are arrangements to review, evaluate and report on the

effectiveness of internal financial control including the establishment of an effective Internal Audit function;

(b) ensuring that the Internal Audit is adequate and meets the NHS mandatory

audit standards;


(c) deciding at what stage to involve the police in cases of misappropriation and other irregularities not involving fraud or corruption;

(e) ensuring that an annual internal audit report is prepared for the consideration

of the Audit and Finance Committee and the Board. The report must cover:

(i) a clear opinion on the effectiveness of internal control in accordance with current assurance framework guidance issued by the Department of Health including for example compliance with control criteria and standards;

(ii) major internal financial control weaknesses discovered; (iii) progress on the implementation of internal audit recommendations; (iv) progress against plan over the previous year; (v) strategic audit plan covering the coming three years; (vi) a detailed plan for the coming year.

11.2.2 The Director of Finance and Procurement or designated auditors are entitled

without necessarily giving prior notice to require and receive:

(a) access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

(b) access at all reasonable times to any land, premises or members of the

Board or employee of the Trust; (c) the production of any cash, stores or other property of the Trust under a

member of the Board and / or an employee's control; and

(d) explanations concerning any matter under investigation. 11.3 Role of Internal Audit 11.3.1 Internal Audit will review, appraise and report upon:

(a) the extent of compliance with, and the financial effect of, relevant established policies, plans and procedures;

(b) the adequacy and application of financial and other related management controls;

(c) the suitability of financial and other related management data; (d) the extent to which the Trust‟s assets and interests are accounted for and

safeguarded from loss of any kind, arising from:

(i) fraud and other offences; (ii) waste, extravagance, inefficient administration; (iii) poor value for money or other causes.

(e) Internal Audit shall also independently verify the Assurance Statements in

accordance with guidance from the Department of Health. 11.3.2 Whenever any matter arises which involves, or is thought to involve, irregularities

concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Director of Finance and Procurement must be notified immediately.


11.3.3 The Head of Internal Audit will normally attend Audit and Finance Committee meetings and has a right of access to all Audit and Finance Committee members, the Chairman and Chief Executive of the Trust.

11.3.4 The Head of Internal Audit shall be accountable to the Director of Finance and

Procurement. The reporting system for internal audit shall be agreed between the Director of Finance and Procurement, the Audit and Finance Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the guidance on reporting contained in the NHS Internal Audit Standards. The reporting system shall be reviewed at least every three years.

11.3.5 Managers in receipt of audit reports referred to them have a duty to take appropriate

remedial action within the timescales specified in the report. The Director of Finance and Procurement shall identify a formal review process to monitor the extent of compliance with audit recommendations. Where appropriate remedial action has failed to take place within a reasonable period, the matter shall be reported to the Director of Finance and Procurement. Changes implemented must be maintained in the future and not viewed as merely satisfying an immediate audit point.

11.4 External Audit 11.4.1 The External Auditor is appointed by the Audit Commission and paid for by the

Trust. The Audit and Finance Committee must ensure a cost-efficient service. If there are any problems relating to the service provided by the External Auditor, then this should be raised with the External Auditor and referred on to the Audit Commission if the issue cannot be resolved.

11.5 Fraud and Corruption 11.5.1 In line with their responsibilities, the Trust Chief Executive and Director of Finance

and Procurement shall monitor and ensure compliance with Directions issued by the Secretary of State for Health on fraud and corruption.

11.5.2 The Trust shall nominate a suitable person to carry out the duties of the Local

Counter Fraud Specialist as specified by the NHS Counter Fraud and Corruption Manual and guidance.

11.5.3 The Local Counter Fraud Specialist shall report to the Trust Director of Finance and

Procurement and shall work with staff in NHS Protect (previously known as the Counter Fraud and Security Management Services (CFSMS)) in accordance with the NHS Counter Fraud and Corruption Manual and guidance.

11.5.4 The Local Counter Fraud Specialist will provide a written report, at least annually,

on counter fraud work within the Trust. 11.5.5 The Trust shall ensure that a Counter Fraud Policy is in place, implemented, and

reviewed and updated to ensure compliance with the Secretary of State Directions on fraud and corruption

11.6 Security Management 11.6.1 In line with their responsibilities, the Trust Chief Executive will monitor and ensure

compliance with Directions issued by the Secretary of State for Health on NHS security management.

11.6.2 The Trust shall nominate a suitable person to carry out the duties of the Local

Security Management Specialist (LSMS) as specified by the Secretary of State for Health guidance on NHS security management.


11.6.3 The Trust shall nominate a Non-Executive Director to be responsible to the Board for NHS security management.

11.6.4 The Chief Executive has overall responsibility for controlling and coordinating

security. However, key tasks are delegated to the Director of Development and the Estate and the appointed Local Security Management Specialist (LSMS).

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12. RESOURCE LIMIT CONTROL

Not applicable to NHS Trusts.

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13. ALLOCATIONS, PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING

13.1 Preparation and Approval of Plans and Budgets 13.1.1 The Chief Executive will compile and submit to the Board an annual Integrated

Business Plan which takes into account financial targets and forecast limits of available resources. The annual Business Plan will contain:

(a) a statement of the significant assumptions on which the plan is based;

(b) details of major changes in workload, delivery of services or resources

required to achieve the plan. 13.1.2 Prior to the start of the financial year the Director of Finance and Procurement will,

on behalf of the Chief Executive, prepare and submit budgets for approval by the Board. Such budgets will:

(a) be in accordance with the aims and objectives set out in the annual Business

Plan; (b) accord with workload and manpower plans; (c) be produced following discussion with appropriate budget managers (d) be prepared within the limits of available funds; (e) identify potential risks.

13.1.3 The Director of Finance and Procurement shall monitor financial performance against budget and plan, periodically review them, and report to the Board.

13.1.4 All budget Managers must provide information as required by the Director of

Finance and Procurement to enable budgets to be compiled. 13.1.5 All budget managers will sign up to their allocated budgets at the commencement of

each financial year. 13.1.6 The Director of Finance and Procurement has a responsibility to ensure that

adequate training is delivered on an on-going basis to budget managers to help them manage successfully.

13.3 Budgetary Delegation 13.3.1 The Chief Executive may delegate the management of a budget to permit the

performance of a defined range of activities. This delegation must be in writing and be accompanied by a clear definition of: (a) the amount of the budget; (b) the purpose(s) of each budget heading; (c) individual and group responsibilities; (d) authority to exercise virement; (e) achievement of planned levels of service; (f) the provision of regular reports.

13.3.2 The Chief Executive and delegated budget managers must not exceed the budgetary total or virement limits set by the Board.


13.3.3 Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Executive, subject to any authorised use of virement.

13.3.4 Non-recurring budgets should not be used to finance recurring expenditure without

the authority in writing of the Chief Executive, as advised by the Director of Finance and Procurement.

13.4 Budgetary Control and Reporting 13.4.1 The Director of Finance and Procurement will devise and maintain systems of

budgetary control. These will include:

(a) monthly financial reports to the Board in a form approved by the Board containing:

(i) income and expenditure to date showing trends and forecast year-end

position;

(ii) movements in working capital; (iii) Movements in cash and capital;

(iv) capital project spend and projected outturn against plan; (v) explanations of any material variances from plan; (vi) details of any corrective action where necessary and the Chief

Executive's and/or Director of Finance and Procurement's view of whether such actions are sufficient to correct the situation;

(b) the issue of timely, accurate and comprehensible advice and financial reports

to each budget managers, covering the areas for which they are responsible; (c) investigation and reporting of variances from financial, workload and

manpower budgets; (d) monitoring of management action to correct variances; and (e) arrangements for the authorisation of budget transfers.

13.4.2 Each Budget Manager is responsible for ensuring that:

(a) any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Board

(b) the amount provided in the approved budget is not used in whole or in part for

any purpose other than that specifically authorised subject to the rules of virement;

(c) no permanent employees are appointed without the approval of the Chief

Executive other than those provided for within the available resources and manpower establishment as approved by the Board.

13.4.3 The Chief Executive is responsible for identifying and implementing cost

improvements and income generation initiatives in accordance with the requirements of the Annual Business Plan and a balanced budget.


13.5 Capital Expenditure 13.5.1 The general rules applying to delegation and reporting shall also apply to capital

expenditure. (The particular applications relating to capital are contained in SFI section24).

13.6 Monitoring Returns 13.6.1 The Chief Executive is responsible for ensuring that the appropriate monitoring

forms are submitted to the requisite monitoring organisation.

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14. ANNUAL ACCOUNTS AND REPORTS 14.1 The Director of Finance and Procurement, on behalf of the Trust, will:

(a) prepare financial returns in accordance with the accounting policies and guidance given by the Department of Health and the Treasury, the Trust‟s accounting policies, and generally accepted accounting practice, as embodied in the International Financial Reporting Standards (IFRS);

(b) prepare and submit annual financial reports to the Department of Health

certified in accordance with current guidelines; (c) submit financial returns to the Department of Health for each financial year in

accordance with the timetable prescribed by the Department of Health. 14.2 The Trust‟s annual accounts must be audited by an auditor appointed by the Audit

Commission. The Trust‟s audited annual accounts must be presented to a public meeting and made available to the public.

14.3 The Trust will publish an annual report, in accordance with guidelines on local

accountability, and present it at a public meeting. The document will comply with the Department of Health's Manual for Accounts.

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15. BANK, AND GOVERNMENT BANKING SERVICE (GBS) ELECTRONIC

ACCOUNTS 15.1 General 15.1.1 The Director of Finance and Procurement is responsible for managing the Trust‟s

banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance/ Directions issued from time to time by the Department of Health. In line with „Cash Management in the NHS‟ Trusts should minimize the use of commercial bank accounts and use the electronic banking systems of the Government Banking Service (GBS) for all banking services.

15.1.2 The Board shall approve the banking arrangements. 15.2 Bank Accounts 15.2.1 The Director of Finance and Procurement is responsible for:

(a) bank accounts, and the trust accounts associated with the electronic banking system run on behalf of GBS

(b) establishing separate bank accounts for the Trust‟s non-exchequer funds; (c) ensuring payments made from bank or GBS accounts do not exceed the

amount credited to the account except where arrangements have been made;

(d) reporting to the Board all arrangements made with the Trust‟s bankers for

accounts to be overdrawn. (e) monitoring compliance with DH guidance on the level of cleared funds.

15.3 Banking Procedures 15.3.1 The Director of Finance and Procurement will prepare detailed instructions on the

operation of bank and GBS accounts which must include:

(a) the conditions under which each bank and GBS account is to be operated; (b) those authorised to sign cheques or other orders drawn on the Trust‟s

accounts.

(c ) the limit to be applied to any overdraft;

15.3.2 The Director of Finance and Procurement must advise the Trust‟s bankers in writing of the conditions under which each account will be operated.

15.3.3 The Director of Finance and Procurement shall approve security procedures for any

cheques issued without a handwritten signature. Manually produced cheques shall be signed by the authorized officer(s) in accordance with the bank mandate. All cheques shall be treated as controlled stationary, in charge of a duly designated officer controlling their issue.

15.4 Tendering and Review 15.4.1 The Director of Finance and Procurement will review the commercial banking

arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust‟s commercial banking business.


15.4.2 Competitive tenders should be sought at least every five years. The results of the tendering exercise should be reported to the Board. This review is not necessary for GBS accounts.

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16. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

16.1 Income Systems 16.1.1 The Director of Finance and Procurement is responsible for designing, maintaining

and ensuring compliance with systems for the proper recording, invoicing, collection and coding of all monies due.

16.1.2 The Director of Finance and Procurement is also responsible for the prompt banking

of all monies received. 16.2 Fees and Charges 16.2.1 The Trust shall follow relevant Department of Health advice in setting prices for

NHS service agreements and contracts with other non-NHS organizations. 16.2.2 The Director of Finance and Procurement is responsible for approving and regularly

reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary. Where sponsorship income (including items in kind such as subsidised goods or loans of equipment) is considered the guidance in the Department of Health‟s Commercial Sponsorship – Ethical standards in the NHS shall be followed.

16.2.3 All employees must inform the Director of Finance and Procurement promptly of

money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

16.3 Debt Recovery 16.3.1 The Director of Finance and Procurement is responsible for the appropriate

recovery action on all outstanding debts. 16.3.2 Income not received should be dealt with in accordance with losses procedures. 16.3.3 Overpayments should be detected (or preferably prevented) and recovery initiated. 16.4 Security of Cash, Cheques and other Negotiable Instruments 16.4.1 The Director of Finance and Procurement is responsible for:

(a) approving the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable (no form of receipt which has not been specifically authorized by the Director of Finance and Procurement should be used) ;

(b) ordering and securely controlling any such stationery; (c) the provision of adequate facilities and systems for employees whose duties

include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines;

(d) prescribing systems and procedures for handling cash and negotiable

securities on behalf of the Trust. 16.4.2 Official money shall not under any circumstances be used for the encashment of

private cheques or IOUs.


16.4.3 All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be made from cash received, except under arrangements approved by the Director of Finance and Procurement.

16.4.4 The holders of safe keys shall not accept unofficial funds for depositing in their safes

unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

16.5 Money Laundering 16.5.1 To minimise the risk of being used for money laundering purposes and avoid the

need to comply with the Money Laundering Regulations the Trust will not accept payment in cash exceeding £1000 for any single transaction other than in respect of funds banked on behalf of a patient who has been admitted with such funds.

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17. TENDERING AND CONTRACTING PROCEDURE 17.1 Duty to comply with Standing Orders and Standing Financial Instructions The procedure for making all contracts by or on behalf of the Trust shall comply

with these Standing Orders and Standing Financial Instructions (except where Standing Order No. 3.13 Suspension of Standing Orders is applied).

17.1.2 Prior to tenders being invited, it must be confirmed that funding approval has been

granted by the relevant board or committee; the proposed goods, services or works have been adequately specified; as appropriate, the design brief and drawings have

been approved and signed off by the primary users; any required statutory approvals have been obtained. 17.2 EU Directives Governing Public Procurement 17.2.1 Directives by the Council of the European Union promulgated by the Department of

Health (DH) prescribing procedures for awarding all forms of contracts shall have effect as if incorporated in these Standing Orders and Standing Financial Instructions.

17.2.2 Nothing in the Standing Financial Instructions can override these Directives 17.3 Reverse eAuctions The Trust should have policies and procedures in place for the control of all

tendering activity carried out through Reverse eAuctions and by means of electronic quotation or tendering. For further guidance on Reverse eAuctions refer to www.ogc.gov.uk

17.4 Capital Investment Manual and other Department of Health Guidance The Trust shall comply as far as is practicable with the requirements of the

Department of Health "Capital Investment Manual" and “Estate code” in respect of capital investment and estate and property transactions. In the case of management consultancy contracts the Trust shall comply as far as is practicable with Department of Health guidance "The Procurement and Management of Consultants within the NHS".

17.5 Formal Competitive Tendering (contract value of £50,000 excluding VAT

or more) 17.5.1 General Applicability

Where the value of a contract over the life of the contract is £50,000 (excluding VAT) or more, the Trust shall ensure that, unless national contracts or Procure 21 or

similar procedures are followed, competitive tenders are invited for: :

the supply of goods, materials and manufactured articles;

the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health);

For the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens);

The maintenance of equipment

for disposals.


17.5.2 Health Care Services

Where the Trust elects to invite tenders for the supply of healthcare services these

Standing Orders and Standing Financial Instructions shall apply as far as they are applicable to the tendering procedure and need to be read in conjunction with Standing Financial Instruction No. 18 and No. 19.

17.5.3 Exceptions and instances where formal tendering need not be applied Formal tendering procedures need not be applied where: (a) the estimated expenditure or income does not, or is not reasonably

expected to, exceed £50,000; (exclusive of VAT) (this figure to be reviewed annually);

(b) where the supply is proposed under special arrangements negotiated

by the DH in which event the said special arrangements must be complied with;

(c) regarding disposals as set out in Standing Financial Instructions No.

25; Formal tendering procedures may only be waived in the following

circumstances: (d) in very exceptional circumstances where the Chief Executive decides

that formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures, and the circumstances are detailed in an appropriate Trust record;

(e) where the requirement is covered by an existing contract;

(f) where “OGC-Buying Solutions” NHS Supply Chain or any other public

sector led (e.g. NHS collaborative procurement hub) agreements are in place which are legally constructed to permit our participation:

(g) where a consortium or a national arrangement is in place and a lead

organization has been appointed to carry out tendering activity on behalf of the consortium members where the Director of Finance & Procurement is satisfied that the consortium procurement arrangements conform to current statute and deliver value for money;

(h) where the timescale genuinely precludes competitive tendering but

failure to plan the work properly would not be regarded as a justification for a single tender;

(i) where there is only one supplier of the goods or services or where

specialist expertise is required and is available from only one source; (j) when the task is essential to complete the project, and arises as a

consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate;

(k) there is a clear benefit to be gained from maintaining continuity with an

earlier project. However in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering;


(l) for the provision of legal advice and services providing that any legal firm or partnership commissioned by the Trust is regulated by the Law Society for England and Wales for the conduct of their business (or by the Bar Council for England and Wales in relation to the obtaining of Counsel‟s opinion) and are generally recognised as having sufficient expertise in the area of work for which they are commissioned.

The Director of Finance and Procurement will ensure that any fees

paid are reasonable and within commonly accepted rates for the costing of such work.

(m) where allowed and provided for in the Guidance issued by the

Department of Health. (n) Where goods are genuinely only available from only one supplier (this

must be substantiated by documentary evidence) The waiving of competitive tendering procedures should not be used to

avoid competition or for administrative convenience or to award further work to a consultant originally appointed through a competitive procedure.

However, non-competitive tenders will still be sought in cases where anticipated expenditure or income exceeds £50,000 but competitive tendering is waived under (d) to (n) above. Where special arrangements referred to in (b) above or national arrangements referred to in (g) above (e.g. OGC, NHS Supply Chain and ProCure21) apply, then non-competitive tendering procedures will not be required. Similarly, where the Guidance issued by the Department of Health so provides, non-competitive as well as competitive tendering may be waived.

Where it is decided that competitive tendering is not applicable and

should be waived, the fact of the waiver and the reasons should be documented and recorded in an appropriate Trust record and reported to the Audit and Finance Committee at each meeting.

17.5.4 Fair and Adequate Competition Where the exceptions set out in SFI Nos. 17.1 and 17.5.3 apply, the Trust shall

ensure that invitations to tender are sent to a sufficient number of firms/individuals to provide fair and adequate competition as appropriate, and in no case less than two firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required.

17.5.5 List of Approved Firms

The Trust shall ensure that the firms/individuals invited to tender (and where appropriate, quote) are among those on approved lists, where approved lists are held either by the Trust or third parties. Seeking of tenders from suppliers not on the approved lists [where such lists exist] shall be treated as a waiver of these SFIs. Such instances must be approved in writing by the Director of Finance & Procurement, recorded in the Tender Waivers Register and reported to the Audit Committee). Where Framework Agreements have been tendered, the rotation of firms may depend upon particular expertise otherwise on a fair basis. Under EU procurement regulations the restriction of competition to approved lists of companies is not permitted and therefore such lists should not be held for goods/services where the threshold captures a significant proportion of tendered business.

17.5.6 Building and Engineering Construction Works


Competitive Tendering cannot be waived for building and engineering construction

works and maintenance (other than in accordance with Concode) without Departmental of Health approval.

17.5.7 Items which subsequently breach thresholds after original approval Items estimated to be below the limits set in this Standing Financial Instruction for

which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the Chief Executive, and be recorded in an appropriate Trust record.

17.6 Contracting/Tendering Procedure 17.6.1 Invitation to tender (i) All invitations to tender shall state the date and time as being the latest time

for the receipt of tenders.

All invitations to tender shall state that no tender will be accepted unless:

(a) submitted in a plain sealed package or envelope bearing a pre-printed label supplied by the Trust (or the word "tender" followed by the subject to which it relates) and the latest date and time for the receipt of such tender addressed to the Chief Executive or nominated Manager; (b) that tender envelopes/ packages shall not bear any names or marks indicating the sender. The use of courier/postal services must not identify the sender on the envelope or on any receipt so required by the deliverer.

(iii) Every tender for goods, materials, services (including consultancy services)

or disposals shall embody such of the NHS Standard Contract Conditions as are applicable. Every tenderer must have given or give a written undertaking not to engage in collusive tendering or other restrictive practices.

(iv) Every tender for building or engineering works (except for maintenance

work, when Estmancode guidance shall be followed) shall embody or be in the terms of the current edition of one of the Joint Contracts Tribunal Standard Forms of Building Contract or Department of the Environment (GC/Wks) Standard forms of contract amended to comply with concode; or, when the content of the work is primarily engineering, the General Conditions of Contract recommended by the Institution of Mechanical and Electrical Engineers and the Association of Consulting Engineers (Form A), or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institute of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. These documents shall be modified and/or amplified to accord with Department of Health guidance and, in minor respects, to cover special features of individual projects.

17.6.2 Receipt and safe custody of tenders The Chief Executive or his/her nominated representative will be responsible for the

receipt, endorsement and safe custody of tenders received until the time appointed for their opening.

The date and time of receipt of each tender shall be endorsed on the tender

envelope/package. 17.6.3 Opening tenders and Register of tenders


(i) As soon as practicable after the date and time stated as being the latest time

for the receipt of tenders, they shall be opened by two senior officers/managers designated by the Chief Executive and not from the originating department.

(ii) A member of the Trust Board will be required to be one of the two approved

persons present for the opening of tenders estimated above £1,000,000. The rules relating to the opening of tenders will need to be read in conjunction with any delegated authority set out in the Trust‟s Scheme of Delegation.

(iii) The „originating‟ Department will be taken to mean the Department sponsoring or commissioning the tender. (iv) The involvement of Finance Directorate staff in the preparation of a tender

proposal will not preclude the Director of Finance and Procurement or any approved Senior Manager from the Finance Directorate from serving as one of the two senior managers to open tenders.

(v) All Executive Directors/members will be authorised to open tenders

regardless of whether they are from the originating department provided that the other authorised person opening the tenders with them is not from the originating department.

The Trust‟s Company Secretary, should the Trust have one, will count as a Director for the purposes of opening tenders.

(vi) Every tender received shall be marked with the date of opening and initiated

by those present at the opening. (vii) A register shall be maintained by the Chief Executive, or a person authorised

by him/her, to show for each set of competitive tender invitations despatched: - the name of all firms individuals invited; - the names of firms individuals from which tenders have been received;

- the date the tenders were opened; - the persons present at the opening;

- the price shown on each tender; - a note where price alterations have been made on the tender. Each entry to this register shall be signed by those present. A note shall be made in the register if any one tender price has had so many

alterations that it cannot be readily read or understood. (viii) Incomplete tenders, i.e. those from which information necessary for the

adjudication of the tender is missing, and amended tenders i.e., those amended by the tenderer upon his own initiative either orally or in writing after the due time for receipt, but prior to the opening of other tenders, should be dealt with in the same way as late tenders. (Standing Order No. 17.6.5 below).

17.6.4 E-Tendering

In the case of goods and services procured via E-tendering, the above procedure will be modified to reflect that:-

Tenders are received electronically by the E-tendering system

Tenders will be opened at the official opening time / date by procurement staff and the system will maintain a log of access.

The system will log any documents added during the procurement period and all communication between the parties using the system


Any amendments to documents post opening will be logged manually along with the identity of the person making the change and the reason for the change.

The system‟s audit log and the manual log will be periodically reviewed by a senior officer and will be available for inspection by Internal Audit as and when required.

17.6.5 Admissibility i) If for any reason the designated officers are of the opinion that the tenders

received are not strictly competitive (for example, because their numbers are insufficient or any are amended, incomplete or qualified) no contract shall be awarded without the approval of the Chief Executive.

(ii) Where only one tender is sought and/or received, the Chief Executive and

Director of Finance and Procurement shall, as far practicable, ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust.

17.6.6 Late tenders (i) Tenders received after the due time and date, but prior to the opening of the

other tenders, may be considered only if the Chief Executive or his/her nominated officer decides that there are exceptional circumstances i.e. despatched in good time but delayed through no fault of the tenderer.

(ii) Only in the most exceptional circumstances will a tender be considered which

is received after the opening of the other tenders and only then if the tenders that have been duly opened have not left the custody of the Chief Executive or his/her nominated officer or if the process of evaluation and adjudication has not started.

(iii) While decisions as to the admissibility of late, incomplete or amended tenders

are under consideration, the tender documents shall be kept strictly confidential, recorded, and held in safe custody by the Chief Executive or his/her nominated officer.

17.6.7 Acceptance of formal tenders (See overlap with SFI No. 17.7) (i) Any discussions with a tenderer which are deemed necessary to clarify

technical aspects of his/her tender before the award of a contract will not disqualify the tender.

(ii) The lowest tender, if payment is to be made by the Trust, or the highest, if

payment is to be received by the Trust, shall be accepted unless there are good and sufficient reasons to the contrary. Such reasons shall be set out in either the contract file, or other appropriate record.

It is accepted that for professional services such as management

consultancy, the lowest price does not always represent the best value for money. Other factors affecting the success of a project include:

(a) experience and qualifications of team members; (b) understanding of client‟s needs; (c) feasibility and credibility of proposed approach;


(d) ability to complete the project on time.

Where other factors are taken into account in selecting a tenderer, these must be clearly recorded and documented in the contract file, and the reason(s) for not accepting the lowest tender clearly stated.

(iii) No tender shall be accepted which will commit expenditure in excess of that

which has been allocated by the Trust and which is not in accordance with these Instructions except with the authorisation of the Chief Executive.

(iv) The use of these procedures must demonstrate that the award of the contract

was:

(a) not in excess of the going market rate / price current at the time the contract was awarded;

(b) that best value for money was achieved.

(v) Subject to the Freedom of Information Act, all tenders should be treated as confidential and should be retained for inspection.

17.6.8 Tender reports to the Trust Board Reports to the Trust Board will be made on an exceptional circumstance basis only. 17.6.9 List of approved firms (see SFI No. 17.5.5) (a) Responsibility for maintaining list A manager nominated by the Chief Executive shall on behalf of the Trust maintain

lists of approved firms from who tenders and quotations may be invited. These shall be kept under frequent review. The lists shall include all firms who have applied for permission to tender and as to whose technical and financial competence the Trust is satisfied. All suppliers must be made aware of the Trust‟s terms and conditions of contract. Under EU procurement rules it is not permitted to restrict competition to an approved list where the expenditure exceeds the relevant threshold.

(b) Building and Engineering Construction Works (i) Invitations to tender shall be made only to firms included on the approved list

of tenderers compiled in accordance with this Instruction or on the separate maintenance lists compiled in accordance with Estmancode guidance (Health Notice HN(78)147).

ii) Firms included on the approved list of tenderers shall ensure that when

engaging, training, promoting or dismissing employees or in any conditions of employment, shall not discriminate against any person because of colour, race, ethnic or national origins, religion or sex, and will comply with the provisions of the Equal Pay Act 1970, the Sex Discrimination Act 1975, the Race Relations Act 1976, and the Disabled Persons (Employment) Act 1944 and any amending and/or related legislation.

iii) Firms shall conform at least with the requirements of the Health and Safety at

Work Act and any amending and/or other related legislation concerned with the health, safety and welfare of workers and other persons, and to any relevant British Standard Code of Practice issued by the British Standard Institution. Firms must provide to the appropriate manager a copy of its


safety policy and evidence of the safety of plant and equipment, when requested.

(c) Financial Standing and Technical Competence of Contractors The Director of Finance and Procurement may make or institute any

enquiries he/she deems appropriate concerning the financial standing and financial suitability of approved contractors. The Director with lead responsibility for clinical governance will similarly make such enquiries as is felt appropriate to be satisfied as to their technical / medical competence.

17.6.10 Exceptions to using approved contractors If in the opinion of the Chief Executive and the Director of Finance and Procurement

or the Director with lead responsibility for clinical governance it is impractical to use a potential contractor from the list of approved firms/individuals (for example where specialist services or skills are required and there are insufficient suitable potential contractors on the list), or where a list for whatever reason has not been prepared, the Chief Executive should ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

An appropriate record in the contract file should be made of the reasons for inviting

a tender or quote other than from an approved list. 17.7 Quotations: Competitive and non-competitive 17.7.1 General Position on quotations Quotations are required where formal tendering procedures are not adopted and

where the intended expenditure or income exceeds, or is reasonably expected to exceed £5000 but not exceed £50,000. For intended expenditure between £2000 but not exceeding £5000, a single written quote is sufficient and for intended expenditure below £2000, a verbal quote will suffice.

Where the potential supplier has the ability to use an e-quote system, this should be used in preference to a manual system.

17.7.2 Competitive Quotations (i) Quotations should be obtained from at least 3 firms/individuals based on

specifications or terms of reference prepared by, or on behalf of, the Trust. (ii) Quotations should be in writing unless the Chief Executive or his/her nominated

officer determines that it is impractical to do so in which case quotations may be obtained by telephone. Confirmation of telephone quotations should be obtained as soon as possible and the reasons why the telephone quotation was obtained should be set out in a permanent record.

(iii) Subject to the Freedom of Information Act, all quotations should be treated

as confidential and should be retained for inspection. (iv) The Chief Executive or his/her nominated officer should evaluate the

quotation and select the quote which gives the best value for money. If this is not the lowest quotation if payment is to be made by the Trust, or the highest if payment is to be received by the Trust, then the choice made and the reasons why should be recorded in a permanent record.

17.7.3 Non-Competitive Quotations (contract value under £5,000 excluding VAT)


Non-competitive quotations in writing may be obtained in the following

circumstances: (i) the supply of proprietary or other goods of a special character and the

rendering of services of a special character, for which it is not, in the opinion of the responsible officer, possible or desirable to obtain competitive quotations;

(ii) the supply of goods or manufactured articles of any kind which are required

urgently and are not obtainable under existing contracts;

(iii) miscellaneous services, supplies and disposals; (iv) where the goods or services are for building and engineering maintenance

the responsible works manager must certify that the first two conditions of this SFI (i.e.: (i) and (ii) of this SFI) apply.

17.7.4 Quotations to be within Financial Limits No quotation shall be accepted which will commit expenditure in excess of that

which has been allocated by the Trust and which is not in accordance with Standing Financial Instructions except with the authorisation of either the Chief Executive or Director of Finance and Procurement.

17.8 Authorisation of Tenders and Competitive Quotations Providing all the conditions and circumstances set out in these Standing Financial

Instructions have been fully complied with, formal authorisation and awarding of a contract may be ratified by the following staff to the value of the contract as follows:

Head of Procurement up to £101,323 (current OJEU Threshold) Director of Finance & Procurement / Chief Executive up to £999,999 Trust Board over £1 Million

These levels of authorisation may be varied or changed and need to be read in

conjunction with the Trust Board‟s Scheme of Delegation. Formal authorisation must be put in writing. In the case of authorisation by the

Trust Board this shall be recorded in their minutes. 17.9 Instances where formal competitive tendering or competitive quotation is not

required Where competitive tendering or a competitive quotation is not required the Trust

should adopt one of the following alternatives: (a) the Trust shall use the NHS Supply Chain for procurement of all goods and

services unless the Chief Executive or nominated officers deem it inappropriate. The decision to use alternative sources must be documented.

(b) If the Trust does not use the NHS Supply Chain - where tenders or quotations

are not required, because expenditure is below £5000, the Trust shall procure goods and services in accordance with procurement procedures approved by the Director of Finance and Procurement.

17.10 Private Finance for capital procurement (see overlap with SFI No. 24)


The Trust should normally market-test for PFI (Private Finance Initiative funding) when considering a capital procurement. When the Board proposes, or is required, to use finance provided by the private sector the following should apply:

(a) The Chief Executive shall demonstrate that the use of private finance

represents value for money and genuinely transfers risk to the private sector.

(b) Where the sum exceeds delegated limits, a business case must be

referred to the appropriate Department of Health for approval or treated as per current guidelines.

(c) The proposal must be specifically agreed by the Board of the Trust, in the

light of such professional advice as should reasonably be sought in particular with regard to vires.

(d) The selection of a contractor/finance company must be on the basis

of competitive tendering or quotations. 17.11 Compliance requirements for all contracts The Board may only enter into contracts on behalf of the Trust within the statutory

powers delegated to it by the Secretary of State and shall comply with:

(a) The Trust‟s Standing Orders and Standing Financial Instructions;

(b) EU Directives and other statutory provisions;

(c) any relevant directions including the Capital Investment Manual, Estatecode and guidance on the Procurement and Management of Consultants;

(d) such of the NHS Standard Contract Conditions as are applicable.

(e) contracts with Foundation Trusts must be in a form compliant with

appropriate NHS guidance.

(f) Where appropriate contracts shall be in or embody the same terms and conditions of contract as was the basis on which tenders or quotations were invited.

(g) In all contracts made by the Trust, the Board shall endeavour to

obtain best value for money by use of all systems in place. The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.

17.12 Personnel and Agency or Temporary Staff Contracts The Chief Executive shall nominate officers with delegated authority to enter into

contracts of employment, regarding staff, agency staff or temporary staff service contracts.

17.13 Healthcare Services Agreements (see overlap with SFI No. 18) Service agreements with NHS providers for the supply of healthcare services shall

be drawn up in accordance with the NHS and Community Care Act 1990 and administered by the Trust. Service agreements are not contracts in law and therefore not enforceable by the courts. However, a contract with a Foundation Trust, being a PBC, is a legal document and is enforceable in law.


The Chief Executive shall nominate officers to commission service agreements with providers of healthcare in line with a commissioning plan approved by the Board.

17.14 Disposals (See overlap with SFI No. 26)

Competitive Tendering or Quotation procedures shall not apply to the disposal of:

(a) any matter in respect of which a fair price can be obtained only by negotiation or sale by auction as determined (or pre-determined in a reserve) by the Chief Executive or his/her nominated officer;

(b) obsolete or condemned articles and stores, which may be disposed

of in accordance with the supplies policy of the Trust;

(c) items to be disposed of with an estimated sale value of less than £5000, this figure to be reviewed on a periodic basis;

(d) items arising from works of construction, demolition or site clearance,

which should be dealt with in accordance with the relevant contract;

(e) land or buildings concerning which DH guidance has been issued but subject to compliance with such guidance.

All disposals of items on the asset register which originally cost not less

than £5000 must be notified to the Finance Department.

17.15 In-house Services 17.15.1 The Chief Executive shall be responsible for ensuring that best value for money can

be demonstrated for all services provided on an in-house basis. The Trust may also determine from time to time that in-house services should be market tested by competitive tendering.

17.15.2 In all cases where the Board determines that in-house services should be subject to

competitive tendering the following groups shall be set up: (a) Specification group, comprising the Chief Executive or nominated

officer/s and specialist(s). (b) In-house tender group, comprising representatives of the in-house

team, a nominee of the Chief Executive and technical support. (c) Evaluation team, comprising normally a specialist officer, a supplies

officer and a Director of Finance and Procurement representative. For services having a likely annual expenditure exceeding £1 Million, a non-executive director should be a member of the evaluation team.

17.15.3 All groups should work independently of each other and individual officers may be a

member of more than one group but no member of the in-house tender group may participate in the evaluation of tenders.

17.15.4 The evaluation team shall make recommendations to the Board. 17.15.5 The Chief Executive shall nominate an officer to oversee and manage the contract

on behalf of the Trust. 17.16 Applicability of SFIs on Tendering and Contracting to funds held in trust (see overlap with SFI No. 29)


These Instructions shall not only apply to expenditure from Exchequer funds but also to works, services and goods purchased from the Special Trustees trust funds and private resources.

17.17 Cancellation of Contracts

Except where specific provision is made in model Forms of Contracts or standard Schedules of Conditions approved for use within the National Health Service, there shall be inserted in every written contract a clause empowering the Trust to cancel the contract and to recover from the contractor the amount of any loss resulting from such cancellation, if the contractor shall have offered, given or agreed to give to any person any gift or consideration of any kind as an inducement or reward for doing or forbearing to do or for having done or forborne to do any action in relation to the obtaining or execution of the contract or any other contract with the Trust, or for showing or forbearing to show favour or disfavour to any person in relation to the contracts or any other contract with the Trust, or if the like acts shall have been done by any person employed by him or acting on his behalf (whether with or without the knowledge of the contractor), or if in relation to any contract with the Trust the contractor or any person employed by him or acting on his behalf shall have committed any offence under the Bribery Act 2010 or other appropriate legislation.

17.18 Determination of Contracts for Failure to Deliver Goods or Materials

There shall be inserted in every written contract for the supply of goods or materials a clause to secure that, should the contractor fail to deliver the goods or materials or any portion thereof within the time or times specified in the contract, the Trust may without prejudice determine the contract either wholly or to the extent of such default and purchase other goods or material of similar description to make good (a) such default or (b) (in the event of the contract being wholly determined) the goods or materials remaining to be delivered. The clause shall further secure that the amount by which the cost of so purchasing other goods or materials exceeds the amount which would have been payable to the contractor in respect of the goods or materials shall be recoverable from the contractor. All contracts for building and engineering works shall include provision for Liquidated damages having regards to the CONCODE provisions. Where a sum above the minimum is required, this shall be determined by the Project Officer in accordance with an estimate of the damages the Trust is likely to incur through late completion of the works by the contractor provided that the amount so derived does not in the opinion of the Project Director or their nominee amount to a penalty.

The Project Director shall determine when liquidated damages shall be enforce after consultation with the Design Team and, if the Project Director considers it necessary with lawyers.

17.19 Use of Electronic Auctions

17.19.1 The Trust at its discretion may, if the category of procured goods or service is

suitable, use an electronic auction to obtain tender submissions. The Buying Solutions (formerly PASA) definition of suitability identifies procurements that are of sufficient value to attract competition, with a requirement that can be accurately specified and for which there is a competitive market. It is important when deciding on a category that a firm specification is available. There must be no ambiguity as to the Trust‟s requirements prior to the eAuction. It must be possible to compare the products on a like for like basis.

17.19.2 Under Article 54 (Use of eAuctions) of the Public Sector Directive 2004/18/EC

(which is adopted in the UK by the Public Contracts Regulations 2006), in open,


restricted or negotiated procedures in the case referred to in Article 30 (1) (a) the Trust may decide that the award of a public contract shall be preceded by an electronic auction when the contract specifications can be established with

precision.

17.19.3 The electronic auction shall be based:

either solely on prices when the contract is awarded to the lowest price; or

on prices and/or on the new values of the features indicated in the specification when the contract is awarded to the most economically advantageous tender.

17.19.4 Should it decide to hold an electronic auction, the Trust shall state that fact in the

contract notice.

17.19.5 The specifications shall include, inter alia, the following details:

(a) the features of the products whose costs shall be the subject of electronic auction, provided that such features are quantifiable and can be expressed in figures or percentages;

(b) any limits on the values which may be submitted, as they result from the

specifications relating to the subject of the contract;

(c) the information which will be made available to tenderers in the course of the electronic auction and, where appropriate, when it will be made available to them;

(d) the relevant information concerning the electronic auction process;

(e) the conditions under which the tenderers will be able to bid and, in particular, the minimum differences which will, where appropriate, be required when bidding;

(f) the relevant information concerning the electronic equipment used and

the arrangements and technical specifications for connection.

17.19.6 Before proceeding with the electronic auction, the Trust shall make a full initial

evaluation of the specification in accordance with the award criteria set and the weighting fixed for them. Clarification will also be sought via the paper-based tender route that the tenderers accept the proposed terms and conditions and that the non-collusion document has been completed.

17.19.7 All tenderers who have been selected shall be invited simultaneously by electronic

means to submit prices and/or values. The invitation shall contain all relevant information concerning individual connection to the electronic equipment being used and shall state the date and time of the start of the electronic auction. The electronic auction may take place in a number of successive phases. The electronic auction may not start sooner than two working days after the date on which invitations are sent out.

17.19.8 Throughout each phase of an electronic auction the Trust shall instantaneously

communicate to all tenderers at least sufficient information to enable them to ascertain their relative rankings at any moment. The Trust may also communicate points of clarification via the electronic auction process provided that the specification is not changed in any way and that the information is sent to all participants. The Trust may also at any time announce the number of participants in that phase of the auction. In no case, however, may the Trust disclose the identities of the tenderers during any phase of an electronic auction, nor the values of their bids.


17.19.9 The Trust shall close an electronic auction at either of the following times: (a) in the invitation to take part in the auction, the date and time shall be

indicated, fixed in advance; (b) closure will be when no more new prices are received, or new values which

meet the requirements concerning minimum differences (in this case the Trust shall state in the invitation to take part in the auction the time which will be allowed to elapse after receipt of the last submission before the electronic auction is closed).

17.19.10 When the Trust has closed an electronic auction and satisfied itself as to

specification compliance and value for money, the Trust shall award the contract in accordance with the Trust‟s Standing Orders and Standing Financial Instructions.

17.19.11 The Trust may not have improper recourse to electronic auctions nor may they be

used in such a way as to prevent, restrict or distort competition or to change the subject of the contract as put up for tender in the published contract notice and defined in the specification.

17.19..12 Following tender approval / contract award the electronic tender documents shall

be stored by the electronic auction service provider for the appropriate time period in accordance with Department of Health guidance concerning the preservation, retention and destruction of records.

17.19.13 The selection of the eAuction service provider shall meet the following standards:

Means of communication must not restrict access to a tendering procedure for potential participants. They must be non discriminatory, generally available and capable of operation with IT products in general use.

The communication and storage of tenders must protect the integrity of the content.

17.19.14 The Trust must satisfy itself annually that the appointed service provider has the

necessary protocols in place to meet the above requirements along with satisfactory archive and retrieval processes. The process shall be fully documented by the service provider with agreed service levels. Furthermore, the Trust shall obtain a formal and independent affirmation of the controls operated by any service provider which supports electronic auctions and receive periodic updates of this assurance.

17.20 ICT procurement

There is a need for a consistent approach to ICT procurement, security, development and practice in the Trust, to ensure value for money and that opportunity and risks associated with the above are properly managed. The Trust will have a number of standard policies and procedures. Compliance with these policies and procedures is compulsory. Systems (hardware/software) purchased or in use without due authority from the Director of

Planning & Information will not be supported and may result in disciplinary action being taken.

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18. NHS SERVICE AGREEMENTS FOR PROVISION OF SERVICES (see overlap with SFI No. 17.13)

18.1 Service Level Agreements (SLAs)

The Chief Executive, as the Accountable Officer, is responsible for ensuring the Trust enters into suitable Service Level Agreements (SLA) with service commissioners for the provision of NHS services.

All SLAs should aim to implement the agreed priorities contained within the

Business Plan and wherever possible, be based upon integrated care pathways to reflect expected patient experience. In discharging this responsibility, the Chief Executive should take into account:

the standards of service quality expected;

the relevant national service framework (if any);

the provision of reliable information on cost and volume of services;

the NHS National Performance Assessment Framework;

that SLAs build where appropriate on existing Joint Investment Plans;

that SLAs are based on integrated care pathways.

18.1.2 The Chief Executive shall be responsible for signing NHS Service Agreements over

a value of £150 million in respect of any one agreement. For NHS Service Agreements below the value of £150 million the Director of Finance and Procurement or the Chief Executive shall be responsible for signing. The Director of Finance and Procurement shall report on the progress and outcome of agreement negotiations to the Board.

18.2 Involving Partners and jointly managing risk A good SLA will result from a dialogue of clinicians, users, carers, public health

professionals and managers. It will reflect knowledge of local needs and inequalities. This will require the Chief Executive to ensure that the Trust works with all partner agencies involved in both the delivery and the commissioning of the service required. The SLA will apportion responsibility for handling a particular risk to the party or parties in the best position to influence the event and financial arrangements should reflect this. In this way the Trust can jointly manage risk with all interested parties.

18.3 Reports to Board on SLAs The Chief Executive, as the Accountable Officer, will need to ensure that regular

reports are provided to the Board detailing actual and forecast income from the SLA. This will include information on costing arrangements, which increasingly should be based upon Healthcare Resource Groups (HRGs). Where HRGs are unavailable for specific services, all parties should agree a common currency for application across the range of SLAs.

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19. COMMISSIONING (This section is not normally applicable to NHS Trusts since they are providers

rather than commissioners of health services. However, in limited cases Trusts may be responsible for operational commissioning of services. In these circumstances Trusts should refer to the model SFIs on Commissioning for PCTs and adopt/amend the relevant paragraphs as appropriate).

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20. TERMS OF SERVICE, ALLOWANCES AND PAYMENT OF MEMBERS OF THE TRUST BOARD AND EXECUTIVE COMMITTEE AND EMPLOYEES 20.1 Remuneration and Terms of Service (see overlap with SO No. 4) 20.1.1 In accordance with Standing Orders the Board shall establish a Remuneration and

Appointments Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

20.1.2 The Committee will:

(a) advise the Board about appropriate remuneration and terms of service for the Chief Executive, other executive directors employed by the Trust and other senior employees including:

(i) all aspects of salary (including any performance-related

elements/bonuses); (ii) provisions for other benefits, including pensions and cars; (iii) arrangements for termination of employment and other contractual terms;

(b) make such recommendations to the Board on the remuneration and terms of

service of executive directors of the Board (and other senior employees) to ensure they are fairly rewarded for their individual contribution to the Trust - having proper regard to the Trust‟s circumstances and performance and to the provisions of any national arrangements for such members and staff where appropriate;

(c) monitor and evaluate the performance of individual executive

directors (and other senior employees); (d) advise on and oversee appropriate contractual arrangements for such staff

including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

20.1.3 The Committee shall report in writing to the Board the basis for its

recommendations. The Board shall use the report as the basis for their decisions, but remain accountable for taking decisions on the remuneration and terms of service of executive directors. Minutes of the Board's meetings should record such decisions.

20.1.4 The Board will consider and need to approve proposals presented by the Chief

Executive for the setting of remuneration and conditions of service for those employees and officers not covered by the Committee.

20.1.5 The Trust will pay allowances to the Chairman and non-officer members of the

Board in accordance with instructions issued by the Secretary of State for Health. 20.2 Funded Establishment 20.2.1 The manpower plans incorporated within the annual budget will form the funded

establishment.


20.2.2 The funded establishment of any department may not be varied without confirmation of affordability by the Finance Manager and the prior approval of the approval of the Chief Executive.

. 20.3 Staff Appointments 20.3.1 No director of the Trust Board or employee may engage, re-engage, or re-grade

employees, either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration:

(a) unless authorised to do so by the Chief Executive;

And it is (b) within the limit of their approved budget and funded establishment.

20.3.2 The Board will approve procedures presented by the Chief Executive for the

determination of commencing pay rates, condition of service, etc, for employees. 20.4 Processing Payroll 20.4.1 The Director of Finance and Procurement is responsible, through the payroll

contractor, for:

(a) specifying timetables for submission of properly authorised time records and other notifications;

(b) the final determination of pay and allowances; (c) making payment on agreed dates; (d) agreeing method of payment.

20.4.2 The Director of Finance and Procurement will ensure that appropriate instructions

have been issued regarding: (a) verification and documentation of data;

(b) the timetable for receipt and preparation of payroll data and the payment of

employees and allowances;

(c) maintenance of subsidiary records for superannuation, income tax, social security and other authorised deductions from pay;

(d) security and confidentiality of payroll information; (e) checks to be applied to completed payroll before and after payment; (f) authority to release payroll data under the provisions of the Data Protection

Act; (g) methods of payment available to various categories of employee and

directors; (h) procedures for payment by cheque, bank credit, or cash to employees and

directors; (I) procedures for the recall of cheques and bank credits; (j) pay advances and their recovery;


(k) maintenance of regular and independent reconciliation of pay control accounts;

(l) separation of duties of preparing records and handling cash; (m) a system to ensure the recovery from those leaving the employment of the

Trust of sums of money and property due by them to the Trust. 20.4.3 Appropriately nominated managers have delegated responsibility for:

(a) processing a signed copy of the contract/appointment form and such other documentation as may be required immediately upon an employee commencing duty;

(b) submitting time records, and other notifications in accordance with agreed

timetables;

(c) completing time records and other notifications in accordance with the Director of Finance and Procurement's instructions and in the form prescribed by the Director of Finance and Procurement;

(d) submitting termination forms in the prescribed form immediately upon

knowing the effective date of an employee's or officer‟s resignation, termination or retirement. Where an employee fails to report for duty or to fulfil obligations in circumstances that suggest they have left without notice, the Director of Finance and Procurement must be informed immediately.

20.4.4 Regardless of the arrangements for providing the payroll service, the Director of

Finance and Procurement shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

20.5 Contracts of Employment 20.5.1 The Board shall delegate responsibility to the Director of Workforce for: (a) ensuring that all employees are issued with a Contract of Employment in a

form approved by the Board and which complies with employment legislation; (b) dealing with variations to, or termination of, contracts of employment.

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21. NON-PAY EXPENDITURE 21.1 Delegation of Authority 21.1.1 The Board will approve the level of non-pay expenditure on an annual basis and the

Chief Executive will determine the level of delegation to budget managers. 21.1.2 The Chief Executive will set out: (a) the list of managers who are authorised to place requisitions for the supply of

goods and services; (b) the maximum level of each requisition and the system for authorisation above

that level. 21.1.3 The Chief Executive shall set out procedures on the seeking of professional advice

regarding the supply of goods and services.

21.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services (see overlap with Standing Financial Instruction No. 17)

21.2.1 Requisitioning The requisitioner, in choosing the item to be supplied (or the service to be

performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust‟s Procurement department shall be sought. Where this advice is not acceptable to the requisitioner, the Director of Finance and Procurement (and/or the Chief Executive) shall be consulted. All goods, services, or works shall be ordered on an official Trust Purchase Order except agreed purchases from petty cash or on NHS purchase cards

21.2.2 System of Payment and Payment Verification The Director of Finance and Procurement shall be responsible for the prompt

payment of accounts and claims. Payment of contract invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.

21.2.3 The Director of Finance and Procurement will: (a) advise the Board regarding the setting of thresholds above which quotations

(competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in Standing Orders and Standing Financial Instructions and regularly reviewed; (section e annex 1)

(b) prepare procedural instructions or guidance within the Scheme of Delegation

on the obtaining of goods, works and services incorporating the thresholds; (c) be responsible for the prompt payment of all properly authorised accounts

and claims; (d) be responsible for designing and maintaining a system of verification,

recording and payment of all amounts payable. The system shall provide for:

(i) A list of directors/ employees (including specimens of their signatures) authorised to certify invoices.

(ii) Certification that:


- goods have been duly received, examined and are in accordance with

specification and the prices are correct; - work done or services rendered have been satisfactorily carried out in

accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct;

- in the case of contracts based on the measurement of time, materials or

expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and price and the charges for the use of vehicles, plant and machinery have been examined;

- where appropriate, the expenditure is in accordance with regulations and

all necessary authorisations have been obtained; - the account is arithmetically correct; - the account is in order for payment. (iii) A timetable and system for submission to the Director of Finance and

Procurement of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment.

(iv) Instructions to employees regarding the handling and payment of

accounts within the Finance Department.

(e) be responsible for ensuring that payment for goods and services is only made once the goods and services are received. The only exceptions are set out in SFI No. 21.2.4 below.

21.2.4 Prepayments Prepayments are only permitted where exceptional circumstances apply. In such

instances: (a) Prepayments are only permitted where the financial advantages outweigh the

disadvantages (i.e. cash flows must be discounted to NPV using the National Loans Fund (NLF) rate plus 2%).

(b) The appropriate Director must provide, in the form of a written report, a case

setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;

(c) The Director of Finance and Procurement will need to be satisfied with the

proposed arrangements before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above a stipulated financial threshold);

(d) The budget Manager is responsible for ensuring that all items due under a

prepayment contract are received and they must immediately inform the appropriate Director or Chief Executive if problems are encountered.

21.2.5 Official orders Official Orders must:


(a) be consecutively numbered; (b) be in a form approved by the Director of Finance and Procurement; (c) state the Trust‟s terms and conditions of trade; (d) only be issued to, and used by, those duly authorised by the Director of Finance and Procurement

21.2.6 Duties of Managers and Officers Managers and officers must ensure that they comply fully with the guidance and

limits specified by the Director of Finance and Procurement and that: (a) all contracts (except as otherwise provided for in the Scheme of Delegation),

leases, tenancy agreements and other commitments which may result in a liability are notified to the Director of Finance and Procurement in advance of any commitment being made;

(b) contracts above specified thresholds are advertised and awarded in

accordance with EU rules on public procurement; (c) where consultancy advice is being obtained, the procurement of such advice

must be in accordance with guidance issued by the Department of Health; this is available from the central procurement team on request

(d) no order shall be issued for any item or items to any firm which has made an

offer of gifts, reward or benefit to directors or employees, other than:

(i) isolated gifts of a trivial character or inexpensive seasonal gifts, such as calendars;

(ii) conventional hospitality, such as lunches in the course of working visits

in accordance with the Trusts hospitality policy;

(This provision needs to be read in conjunction with Standing Order No. 6 and the principles outlined in the national guidance contained in HSG 93(5) “Standards of Business Conduct for NHS Staff”);

(e) no requisition/order is placed for any item or items for which there is no

budget provision unless authorised by the Director of Finance and Procurement on behalf of the Chief Executive;

(f) all goods, services, or works are ordered on an official order except works

and services executed in accordance with a contract and purchases from petty cash (subject to the petty cash limit – see scheme of delegated limits) .

(g) verbal orders must only be issued very exceptionally - by an employee

designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked "Confirmation Order";

(h) orders are not split or otherwise placed in a manner devised so as to avoid

the financial thresholds; (i) goods are not taken on trial or loan in circumstances that could commit the

Trust to a future uncompetitive purchase;


(j) changes to the list of employees and officers authorised to certify invoices are notified to the Director of Finance and Procurement;

(k) purchases from petty cash are restricted in value and by type of purchase in

accordance with instructions issued by the Director of Finance and Procurement;

(l) petty cash records are maintained in a form as determined by the Director of

Finance and Procurement. (m) An individual cannot order an item, receipt the item and certify the invoice for

payment (n) The financial limits for officers‟ approval of payments are set out in the

Scheme of Delegated limits

21.2.7 The Director of Finance and Procurement shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within CONCODE and ESTATECODE. The technical audit of these contracts shall be the responsibility of the relevant Director.

21.3 Joint Finance Arrangements with Local Authorities and Voluntary Bodies (see overlap with Standing Order No. 9.1) 21.3.1 Payments to local authorities and voluntary organisations made under the powers of

section 28A of the NHS Act shall comply with procedures laid down by the Director of Finance and Procurement which shall be in accordance with these Acts. (See overlap with Standing Order No. 9.1)

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22. EXTERNAL BORROWING 22.1.1 The Director of Finance and Procurement will advise the Board concerning the

Trust‟s ability to pay dividend on, and repay Public Dividend Capital and any proposed new borrowing, within the limits set by the Department of Health. The Director of Finance and Procurement is also responsible for reporting periodically to the Board concerning the PDC debt and all loans and overdrafts.

22.1.2 The Board will agree the list of employees (including specimens of their signatures)

who are authorised to make short term borrowings on behalf of the Trust. This must contain the Chief Executive and the Director of Finance and Procurement.

22.1.3 The Director of Finance and Procurement must prepare detailed procedural

instructions concerning applications for loans and overdrafts. 22.1.4 All short-term borrowings should be kept to the minimum period of time possible,

consistent with the overall cash flow position, represent good value for money, and comply with the latest guidance from the Department of Health.

22.1.5 Any short-term borrowing must be with the authority of two members of an

authorised panel, one of which must be the Chief Executive or the Director of Finance and Procurement. The Board must be made aware of all short term borrowings at the next Board meeting.

22.1.6 All long-term borrowing must be consistent with the plans outlined in the current

Business Plan and be approved by the Trust Board. 22.2 INVESTMENTS 22.2.1 Temporary cash surpluses must be held only in such public or private sector

investments as notified by the Secretary of State and authorised by the Board. 22.2.2 The Director of Finance and Procurement is responsible for advising the Board on

investments and shall report periodically to the Board concerning the performance of investments held.

22.2.3 The Director of Finance and Procurement will prepare detailed procedural

instructions on the operation of investment accounts and on the records to be maintained.

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23. FINANCIAL FRAMEWORK 23.3.1 The Director of Finance and Procurement should ensure that members of the Board

are aware of the Financial Framework. This document contains directions which the Trust must follow. It also contains directions to Strategic Health Authorities regarding resource and capital allocation and funding to Trust‟s. The Director of Finance and Procurement should also ensure that the direction and guidance in the framework is followed by the Trust.

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24. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

24.1 Capital Investment 24.1.1 The Chief Executive:

(a) shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans;

(b) is responsible for the management of all stages of capital schemes and for

ensuring that schemes are delivered on time and to cost; (c) shall ensure that the capital investment is not undertaken without

confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences.

24.1.2 For every capital expenditure proposal the Chief Executive shall ensure:

(a) that a business case (in line with the guidance issued by the Department of Health) is produced setting out:

(i) an option appraisal of potential benefits compared with known costs to

determine the option with the highest ratio of benefits to costs;

(ii) the involvement of appropriate Trust personnel and external agencies; (iii) appropriate project management and control arrangements;

(b) that the Director of Finance and Procurement has certified professionally to the costs and revenue consequences detailed in the business case.

24.1.3 For capital schemes where the contracts stipulate stage payments, the Chief

Executive will issue procedures for their management, incorporating the recommendations of “Estatecode”.

24.1.4 The Director of Finance and Procurement shall assess on an annual basis the

requirement for the operation of the construction industry tax deduction scheme in accordance with HM Revenue & Customs guidance.

24.1.5 The Director of Finance and Procurement shall issue procedures for the regular

reporting of expenditure and commitment against authorised expenditure. 24.1.6 The approval of a capital programme shall not constitute approval for expenditure

on any scheme.

The Chief Executive shall issue to the manager responsible for any scheme: (a) specific authority to commit expenditure; (b) authority to proceed to tender (see overlap with SFI No. 17.6); (c) approval to accept a successful tender (see overlap with SFI No. 17.6).

The Chief Executive will issue a scheme of delegation for capital investment management in accordance with "Estatecode" guidance and the Trust‟s Standing Orders.


24.1.7 The Director of Finance and Procurement shall issue procedures governing the

financial management, including variations to contract, of capital investment projects and valuation for accounting purposes. These procedures shall fully take into account the delegated limits for capital schemes included in Annex C of HSC (1999) 246.

24.2 Private Finance (see overlap with SFI No. 17.10) 24.2.1 The Trust should normally test for PFI when considering capital procurement. When

the Trust proposes to use finance which is to be provided other than through its Allocations, the following procedures shall apply:

(a) The Director of Finance and Procurement shall demonstrate that the use of

private finance represents value for money and genuinely transfers significant risk to the private sector.

(b) Where the sum involved exceeds delegated limits, the business case must be

referred to the Department of Health or in line with any current guidelines. (c) The proposal must be specifically agreed by the Board.

24.3 Asset Registers 24.3.1 The Chief Executive is responsible for the maintenance of registers of assets, taking

account of the advice of the Director of Finance and Procurement concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

24.3.2 Each Trust shall maintain an asset register recording fixed assets. The minimum

data set to be held within these registers shall be as specified in the guidance issued by the Department of Health.

24.3.3 Additions to the fixed asset register must be clearly identified to an appropriate

budget Manager and be validated by reference to:

(a) properly authorised and approved agreements, architect's certificates, supplier's invoices and other documentary evidence in respect of purchases from third parties;

(b) stores, requisitions and wages records for own materials and labour including

appropriate overheads; (c) lease agreements in respect of assets held under a finance lease and

capitalised.

24.3.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

24.3.5 The Director of Finance and Procurement shall approve procedures for reconciling

balances on fixed assets accounts in ledgers against balances on fixed asset registers.

24.3.6 The value of each asset shall be maintained at current values in accordance with

methods specified in guidance issued by the Department of Health. 24.3.7 The value of each asset shall be depreciated using methods and rates as specified

by the Department of Health.


24.4 Security of Assets 24.4.1 The overall control of fixed assets is the responsibility of the Chief Executive. 24.4.2 Asset control procedures (including fixed assets, cash, cheques and negotiable

instruments, and also including donated assets) must be approved by the Director of Finance and Procurement. This procedure shall make provision for:

(a) recording managerial responsibility for each asset; (b) identification of additions and disposals; (c) identification of all repairs and maintenance expenses; (d) physical security of assets; (e) periodic verification of the existence of, condition of, and title to, assets

recorded; (f) identification and reporting of all costs associated with the retention of an

asset; (g) reporting, recording and safekeeping of cash, cheques, and negotiable

instruments.

24.4.3 All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Director of Finance and Procurement.

24.4.4 Whilst each employee and officer has a responsibility for the security of property of

the Trust, it is the responsibility of Board members and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Board. Any breach of agreed security practices must be reported in accordance with agreed procedures.

24.4.5 Any damage to the Trust‟s premises, vehicles and equipment, or any loss of

equipment, stores or supplies must be reported by Board members and employees in accordance with the procedure for reporting losses.

24.4.6 Where practical, assets should be marked as Trust property. 24.4.7 Private use of Trust assets is not normally permitted. Exceptionally, and with the

prior approval of the relevant director, it will be allowed. In all cases the full costs must be reimbursed to the Trust.

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25. STORES AND RECEIPT OF GOODS 25.1 General position 25.1.1 Stores, defined in terms of controlled stores and departmental stores (for immediate

use) should be:

(a) kept to a minimum; (b) subjected to annual stock take; (c) valued at the lower of cost and net realisable value.

25.2 Control of Stores, Stocktaking, condemnations and disposal 25.2.1 Subject to the responsibility of the Director of Finance and Procurement for the

systems of control, overall responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day-to-day responsibility may be delegated by him/her to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Director of Finance and Procurement. The control of any Pharmaceutical stocks shall be the responsibility of a designated Pharmaceutical Officer; the control of any fuel oil and coal of a designated estates manager.

25.2.2 The responsibility for security arrangements and the custody of keys for any stores

and locations shall be clearly defined in writing by the designated manager/Pharmaceutical Officer. Wherever practicable, stocks should be marked as NHS property.

25.2.3 The Director of Finance and Procurement shall set out procedures and systems to

regulate the stores including records for receipt of goods, issues, and returns to stores, and losses.

25.2.4 Stocktaking arrangements shall be agreed with the Director of Finance and

Procurement and there shall be a physical check covering all items in store at least once a year.

25.2.5 Where a complete system of stores control is not justified, alternative arrangements

shall require the approval of the Director of Finance and Procurement. 25.2.6 The designated Manager/Pharmaceutical Officer shall be responsible for a system

approved by the Director of Finance and Procurement for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Director of Finance and Procurement any evidence of significant overstocking and of any negligence or malpractice (see also overlap with SFI No. 25 Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

25.3 Goods supplied by NHS Supply Chain 25.3.1 The authorised person shall check receipt against the delivery note and report any

exceptions to the delegated officer as approved by the Director of Finance and Procurement. The delegated officer will be responsible for satisfying himself that the goods have been received before accepting the recharge.

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26. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

26.1 Disposals and Condemnations 26.1.1 Procedures The Director of Finance and Procurement must prepare detailed procedures for the

disposal of assets including condemnations, and ensure that these are notified to managers.

26.1.2 When it is decided to dispose of a Trust asset, the Head of Department or

authorised deputy will determine and advise the Director of Finance and Procurement of the estimated market value of the item, taking account of professional advice where appropriate.

26.1.3 All unserviceable articles shall be:

(a) condemned or otherwise disposed of by an employee authorised for that purpose by the Director of Finance and Procurement;

(b) recorded by the Condemning Officer in a form approved by the Director of

Finance and Procurement which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Director of Finance and Procurement.

26.1.4 The Condemning Officer shall satisfy himself as to whether or not there is evidence

of negligence in use and shall report any such evidence to the Director of Finance and Procurement who will take the appropriate action.

26.2 Losses and Special Payments 26.2.1 Procedures The Director of Finance and Procurement must prepare procedural instructions on

the recording of and accounting for condemnations, losses, and special payments. The Director of Finance and Procurement must ensure that a Counter Fraud Policy is in place that sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.

26.2.2 Any employee or officer discovering or suspecting a loss of any kind must either

immediately inform their head of department, who must immediately inform the Chief Executive and the Director of Finance and Procurement or inform an officer charged with responsibility for responding to concerns involving loss. This officer will then appropriately inform the Director of Finance and Procurement and/or Chief Executive. Where a criminal offence is suspected, the Director of Finance and Procurement must immediately inform the police if theft or arson is involved. In cases of fraud and corruption or of anomalies which may indicate fraud or corruption, the Director of Finance and Procurement must inform the relevant LCFS and NHS Protect in accordance with Secretary of State for Health‟s Directions.

The Director of Finance and Procurement must notify NHS Protect and the External

Auditor of all frauds. 26.2.3 For losses apparently caused by theft, arson, neglect of duty or gross carelessness,

except if trivial, the Director of Finance and Procurement must immediately notify:

(a) the Board,


(b) the External Auditor.

26.2.4 Within limits delegated to it by the Department of Health, the Board shall approve the writing-off of losses.

26.2.5 The Director of Finance and Procurement shall be authorised to take any necessary

steps to safeguard the Trust‟s interests in bankruptcies and company liquidations. 26.2.6 For any loss, the Director of Finance and Procurement should consider whether any

insurance claim can be made. 25.2.7 The Director of Finance and Procurement shall maintain a Losses and Special

Payments Register in which write-off action is recorded. 26.2.8 No special payments exceeding delegated limits shall be made without the prior

approval of the Department of Health. 26.2.9 All losses and special payments must be reported to the Audit and Finance

Committee at every meeting.

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27. INFORMATION TECHNOLOGY 27.1 Responsibilities and duties of the Director of Finance and Procurement 27.1.1 The Director of Finance and Procurement, who is responsible for the accuracy and

security of the computerised financial data of the Trust, shall:

(a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Trust‟s data, programs and computer hardware for which the Director is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998 and the Computer Misuse Act 1990;

(b) ensure that adequate (reasonable) controls exist over data entry, processing,

storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;

(c) ensure that adequate controls exist such that the computer operation is

separated from development, maintenance and amendment; (d) ensure that adequate controls exist to maintain security, privacy, accuracy and

completeness of financial data sent via transmission networks; (e) ensure that an adequate management (audit) trail exists through the

computerised system and that such computer audit reviews as the Director may consider necessary are being carried out.

27.1.2 The Director of Finance and Procurement shall need to ensure that new financial

systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

27.1.3 The Chief Executive shall publish and maintain a Freedom of Information (FOI)

Publication Scheme, or adopt a model Publication Scheme approved by the Information Commissioner. A Publication Scheme is a complete guide to the information routinely published by a public authority. It describes the classes or types of information about our Trust that we make publicly available.

27.2 Responsibilities and duties of other Directors and Officers in relation to

computer systems of a general application 27.2.1 In the case of computer systems which are proposed General Applications (i.e.

normally those applications which the majority of Trust‟s in the Region wish to sponsor jointly) all responsible directors and employees will send to the Director of Planning and Information : (a) details of the outline design of the system; (b) in the case of packages acquired either from a commercial organisation, from

the NHS, or from another public sector organisation, the operational requirement.


27.3 Contracts for Computer Services with other health bodies or outside agencies The Director of Finance and Procurement shall ensure that contracts for computer

services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

Where another health organisation or any other agency provides a computer

service for financial applications, the Director of Finance and Procurement shall periodically seek assurances that adequate controls are in operation.

27.4 Risk Assessment

Director of Planning and Information shall ensure that risks to the Trust arising from the use of IT are effectively identified and considered and appropriate action taken to mitigate or control risk. This shall include the preparation and testing of appropriate disaster recovery plans and security arrangements.

27.5 Requirements for Computer Systems which have an impact on corporate

financial systems Where computer systems have an impact on corporate financial systems the

Director of Finance and Procurement shall need to be satisfied that:

(a) systems acquisition, development and maintenance are in line with corporate policies such as an Information Technology Strategy;

(b) data produced for use with financial systems is adequate, accurate, complete

and timely, and that a management (audit) trail exists; (c) Director of Finance and Procurement staff have access to such data; (d) such computer audit reviews as are considered necessary are being carried

out.

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28. PATIENTS' PROPERTY 28.1 The Trust has a responsibility to provide safe custody for money and other personal

property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival.

28.2 The Chief Executive is responsible for ensuring that patients or their guardians, as

appropriate, are informed before or at admission by:

- notices and information booklets; (notices are subject to sensitivity guidance)

- hospital admission documentation and property records; - the oral advice of administrative and nursing staff responsible for admissions,

that the Trust will not accept responsibility or liability for patients' property brought

into Health Service premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.

28.3 The Director of Finance and Procurement must provide detailed written instructions

on the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.

28.4 Where Department of Health instructions require the opening of separate accounts

for patients' moneys, these shall be opened and operated under arrangements agreed by the Director of Finance and Procurement.

28.5 In all cases where property of a deceased patient is of a total value in excess of

£5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965), the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.

28.6 Staff should be informed, on appointment, by the appropriate departmental or senior

manager of their responsibilities and duties for the administration of the property of patients.

28.7 Where patients' property or income is received for specific purposes and held for

safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

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29. FUNDS HELD ON TRUST 29.1 General

The Director of Finance and Procurement shall ensure that each trust fund which the Special Trustee‟s are responsible for managing is managed appropriately with regard to its purpose and to its requirements.

29.2 Accountability to Charity Commission and Secretary of State for Health

(1) The Special Trustee‟s responsibilities must be discharged separately and they are accountable to the Charity Commission for charitable funds held on trust and to the Secretary of State for all funds held on trust.

(2) The Schedule of Matters Reserved to the Board and the Scheme of Delegation

make clear where decisions regarding the exercise of discretion regarding the disposal and use of the funds are to be taken and by whom. All Trust Board members and Trust officers must take account of that guidance before taking action.

29.3 Applicability of Standing Financial Instructions to funds held on Trust

(1) In so far as it is possible to do so, most of the sections of these Standing Financial Instructions will apply to the management of funds held on trust. (See overlap with SFI No 17.16).

(2) The over-riding principle is that the integrity of each Trust must be maintained

and statutory and Trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

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30. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT (see overlap with SO No. 6 and SFI No. 21.2.6 (d))

The Director of Finance and Procurement shall ensure that all staff are made aware

of the Trust policy on acceptance of gifts and other benefits in kind by staff. This policy follows the guidance contained in the Department of Health circular HSG (93) 5 „Standards of Business Conduct for NHS Staff‟ and is also deemed to be an integral part of these Standing Orders and Standing Financial Instructions (see overlap with SO No. 6).

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31. Research & Development

31.1 All research and development activities within the Trust shall be notified to the Medical Director

31.2 The Director of Finance and Procurement shall ensure procedures are put in

place to ensure that all such activities are properly accounted for and that all funding is utilized appropriately.

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32. RETENTION OF RECORDS 32.1 The Chief Executive, through the Director of Planning and Information shall be

responsible for maintaining archives for all records required to be retained in accordance with Department of Health guidelines.

32.2 The records held in archives shall be capable of retrieval by authorised persons. 32.3 Records held in accordance with latest Department of Health guidance shall only be

destroyed at the express instigation of the Chief Executive. Detail shall be maintained of records so destroyed.

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33. RISK MANAGEMENT AND INSURANCE 33.1 Programme of Quality and Risk Management The Chief Executive shall ensure that the Trust has a programme of quality and risk

management, in accordance with current Department of Health assurance framework requirements, which must be approved and monitored by the Board or Board sub committee with delegated authority.

The programme of risk management shall include:

a) a process for identifying and quantifying risks and potential liabilities; b) engendering among all levels of staff a positive attitude towards the control of

risk; c) management processes to ensure all significant risks and potential liabilities

are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;

d) contingency plans to offset the impact of adverse events; e) audit arrangements including; Internal Audit, clinical audit, health and safety

review; f) a clear indication of which risks shall be insured; g) arrangements to review the Risk Management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make a Statement on the effectiveness of Internal Control (SIC) within the Annual Report and Accounts as required by current Department of Health guidance.

33.2 Insurance: Risk Pooling Schemes administered by NHSLA The Board shall decide if the Trust will insure through the risk pooling schemes

administered by the NHS Litigation Authority or self insure for some or all of the risks covered by the risk pooling schemes. If the Board decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme this decision shall be reviewed annually.

33.3 Insurance arrangements with commercial insurers 33.3.1 There is a general prohibition on entering into insurance arrangements with

commercial insurers. There are, however, three exceptions when Trust‟s may enter into insurance arrangements with commercial insurers. The exceptions are:

a) Trust‟s may enter commercial arrangements for insuring motor vehicles

owned by the Trust including insuring third party liability arising from their use; b) where the Trust is involved with a consortium in a Private Finance Initiative

contract and the other consortium members require that commercial insurance arrangements are entered into; and

c) where income generation activities take place. Income generation activities

should normally be insured against all risks using commercial insurance. If the income generation activity is also an activity normally carried out by the Trust for a NHS purpose the activity may be covered in the risk pool. Confirmation of


coverage in the risk pool must be obtained from the Litigation Authority. In any case of doubt concerning a Trust‟s powers to enter into commercial insurance arrangements the Finance Director should consult the Department of Health.

33.4 Arrangements to be followed by the Board in agreeing Insurance cover

a. Where the Board decides to use the risk pooling schemes administered by the NHS Litigation Authority the Director of Finance and Procurement shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Director of Finance and Procurement shall ensure that documented procedures cover these arrangements.

b. Where the Board decides not to use the risk pooling schemes administered by

the NHS Litigation Authority for one or other of the risks covered by the schemes, the Director of Finance and Procurement shall ensure that the Board is informed of the nature and extent of the risks that are self insured as a result of this decision. The Director of Finance and Procurement will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses which will not be reimbursed.

c. All the risk pooling schemes require Scheme members to make some

contribution to the settlement of claims (the „deductible‟). The Director of Finance and Procurement should ensure documented procedures also cover the management of claims and payments below the deductible in each case.

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